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HomeMy WebLinkAbout1571A 1572A (9) � WORKEkS'COMPENSATION�ECLARATION � �' ' `—e`vy oiiirm inaf I have o cen�ifimfe oF consenf to self q�p�l-�qT1�iV FOR �tJILDING PERMIT � '� � insure,or a wrtifimfe cf Workers'Compenstion Ins�rance,or � a certified copy thereof{Sec 3800,Lab.C.) COUNTY OP LOS ANGELES BUILDING AND SAFETY P❑ol�cyNo. �mpony Pac. Indemnitv Ce�tifie c�opy is�e�eby f��nished. FOR APPL�CANT TO FILL IN no�kEss �Z��� �,.���.r+., ��i � cernt�ed�opy is filed w�,n rnP�o��,y b�ad�n9��s���- euao�n��p6 B1d 24 22579 Hilton Head ,[�_v'3 � tion department� A�DRESS g' LOCAIJTY NEARESI oore nppn�anr S,McGinnis c�rr Diamand Bar ziP 9ll65 ceosssr. CERTIP�CATE OF EXEMPTION FROM WORKERS' - NO.OF BLDGS. ?55E550e � COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT O MAP BOOK PAGE PARCEL (This setlian need not be complered if Ihe permif is for one USE ZONE MAP - ����i�o h��d�ed do��ars�$too�o.�ess.) rRncT S$gS3634 iocK �oT No. No. � � iEL. � SPECIAL . � I ce���`y that in;he perforrnunce or`tne work for which this �°��A1C° Ahmanson Dev. uc.818814715 CONDITiONS � p y any person in ony manner UISTRICI GROUP fYVE FiRE PROCESSED�BY pe�m�r�s�ss�ed,i sh�l��or em �o noozess 1001 Commerce Dr. corvsi. zoNe � so as io 6emme subjecl ta the Workers'Compensation Laws. '�� - � �iTr Irwind�le ZiP 91706 >� � Dafe Applicant—__ � ------ ' �STATIST�CALCLA551FICATION APT. C DO. �j NOTICE 70 APPLICANT: If, after making this Certificoie of ARCh'I7ECT OR TEL. Exemprion, ycu should bemme subject to the Workers' ENGWEER B&E Eri . '�']_32�j rj].3 � CtA55 NO. DwEtL UNitS_ � CompensntiCn proe�isions of the Lubor Code,you must(orth- qDDRE55 I,E1 Jd��{Z SEwER MAP � .wifh comply wi�h such provisions or �his perrni� aha�l be ' deemed revoked. � cONTR�QOR [�hipgriSOri DgV. `��77I+$4]1�79�,. �K� �'G- _ VALIDATION LICENSED CONTRACIORS DECLARATION i��. . I here6y afBrm that I am li<ensed under provisions of Ch�pier 9 ' aD�RESS , NO. � yqtUAT10N (mmmencing with Section 7Q�Oj of Division 3 of the 8usiness and ��C. / �� G 7 Professions Code,and my license is in full force and effect. ��iy E1 Toro CLA55 $-1 S �,46 �� � ' ' � k SQ.F1. NO-OF NO-OF CHEIX LicenseNumber �.Q��.RR��R!` LIc.Clqss B`1 SIZE SIORIES FAMILIES ONE �e `� ����� , � NEW � .� ( e e 'I n,.J L� co�o-a�ro, Ahmanson Dev_oare oEscR�Pr�oNOFwoRK Trash Enclosures � I am exempi from the licensing requiremenis as i am a AD� � �.� , �e;C�.1_ licensed architeci or a regislered professionol engineer. . AUER .� P�NAL . � �� � - acting in my professional capacity j5ection 7051, R'ePAIR � DATE �� ��� �� � �,_�rJ Business and Prcfessions Code). , USE OF ���„��� r'l�- FtNAI - . . EXiSTWG BLDG. L.J By f/'!1 /�)_ _ Lic or Reg.Na Dale ArvuCAN7 TEi. g��-ye�—�� � 0�1�NfR-BUILDER DECLARATION (Nk���T1$ �- No. I hereby offirm that I am exempt from tha Contractor's License 22904 Golden S Z'1 ri S D13ID011d B3I' � � Law for fhe followinq reason(Section 7031.5, 8usiness and ` ���RESS P � g . � - V�'G Z� Professions Codc): aRF ENT ❑ BUILDiNG J ' -t:;'° ° o '� � 1 . 1, as owner ol the prcperty, or my employees wiih ADDRE55 , wages as 4heir sole compensalian.will do the work and ihe stru<lure is not intended or offered for sale(Section LUCALiTY � - J�b �j�,�C LJ 70A�,Business ond Profess�ons Code). � � MOVING � 7EL . . � �_ � I,os owner of the proporty,nm�exclusive�y conirocfing CONII2ACTOR NO_ a e m[!�,�(.1� � wfth licensed mntrnctars to mnstruU the projeci(Seo - ADDRE55 tion 7044,Business and Professions Ccde). _ ��� 9'�"i J CONSiRUC�TION LENDING AGENCY �EQUIRED �AR� HWy iOlAl SElt3ACK FROM EXIST - SET BACK PROP.LNE WIDTFi �. - I hereby affirm tha�there i,a construction lending ogency for FROnI' . ihe performance o(the work for which rhis permir Is issued P.L � - (Sec.3097,Gv.C.)_ SIDE . PL ��„de�'s rvn�,e none �P� �ee$ I�`..� Fermil Fce ��..�—z� Lender's Address Y - . I certify ihot I have read ihis application and stafe�hat the �` iss���nce Fee !�"�� � iabove informntien is correc�.I oyree to comply wlih all Counfy `-investigation Pee � ordinances and State laws relaling to building consirucrlon, Toial Fee ��� � � and hereby au�harize representativ s of�his Couniy fa enter �� - - iupon t bove mryrrt ned pr, I for inspectlon.purp es, . . eJ�j�{� f [�, SEE REVERSE FOR EXPLANATOftY LANGUAGE �. � . ' Signaiu�e o!'ApF mn�c�A�e�t Core - �s �.. � � : Q � --�---9�, n �' � � 4 0� �� o a. � � n. a � o a .� -n in n � i� o � 4 m � ao u� � w �; � � O (%t% � Q -� t] n � q =n '�p'� � ._„.�-�--� `r ¢ 7 Q G � 6'L1 +II j 7 (l'3 � 3 . n ����� o� s S � � � n gO � � fl=ea o .° � 3 Q ,� � 0 C � \ c2 l0 �c-- R8" �p u� H� O O -�.� qp � 9 � � -�'�O ' n� � �� 3 7 �� @ �-, '��' � n , � � r�. 1, ^ �� � 6.4 � � � � �3 �p � �. O � ��� 3 � N I O . 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