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HomeMy WebLinkAbout1573A 1574A - WORKERS COMPENSATION DKLARAiION � � insure�oracleriificateohWorkerseColmpensotlonlnsurancesolr APPLI��ATION FOR BUILDING �PE.RMIT � a ccrtified copy thereaf(Sec 3800,Lab.C.� COUNTY OF LOS ANGELES BUIL�ING AND SAFETY P❑ol�cyNo. 7h34—All�ompany Pac. Tndemnitv Ce�tifieA copy is he�eby f��nished. FOR APPLICANT TO FILL IN n�oREss �yt� "'�- � ,Certified copy is filed with the caonty building lnspec- gUl�owG � � uondPpor�me�r. nnoaess4{7 Bld . 24 22879 Hilton �Iead �ocnurr ' S.McGinnis "EAREST �ore nppi��om aTr Diamond Bar zia 91765 ceoss sT CERTIFlCATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS ASSESSOR COMPENSATION INSURANCE 517E OF LOT NOW ON LOT � MAP BOOK PAGE PARCEL (This section need not 6e compleied ii ihe permif is for ane USE ZONE N�AP y),/."'3 r/ hundred dollars($100�or less.� 1NACT 363ZFE7 BtOCK LOT NO. NO. G[�Y � 7 p� TEL SPECIAL I certify thnt in ihe performance of the work for which this OWNER NO. � CONDiTIONS . . ��. (� ermll is issu2d,1 shall not em lo an erson'in an manner UISiRICT GROUP 7YPE FIRE PROCESSED BY gf P � Y y p Y nooREss 1001 Commerce Dr. coNsr. zoNe � so as to become subject to the Workers'Compensotion Laws. Irwindale 9170b � � � � Date Applicant CiTY Z�P . STATIS�ICAL CLASSIFICA710N APi. CONDO. � NOTICE TO APPLICANT: If,-afte�_makiny ihis Certifimte of ARCHITECT OR TEL y� ENGINEER �i�e'�' �'1l Ne�132545134 CLA55 NO. DWELL UNITS_ � Exemption, you should become subject to Ihe Workers' t�} .Compensation provisions�of the Labor Code,you musl torth-� qppRE55 [g 00 1 SeWER MAP � ith comply w"th such provisions or this permit shall be deemed revoked. rr� BK. PG, VALiDATION coNrRacroK Ahmanson Dev. No 714837127. � LICENSED CONTKACTORS DECIARATION �IC. I hereby uffirm thai 1 am licensed under pro�eisions of Chapter 9 ADDKeS< Z3$(j EZ TOTO No. [}(7.j(7$$GB VALUATION (commencing with Section 7000)of Division 3 of the Buslness and �ic ���� -��[ u i,v�, Professions Code,and rny license is in full force and effect. ❑TY EZ TOTO C�FlSS B-1 -g � �Sq.FT. NO.OF NO.OF C41ECK �:q �-a �r 1 ticensa Number 465688GBG Lic Class B-1 S¢E 'SiOk�eS Fn.rtni�ie5 ONF . Conrracfo� Ahmanson Dev. �afe oEscRiaTion oF woRK Trash Enclosures NEw $ ( � a 1 9.{� ❑ ADD � I am exempt from the licensing requiremenis qs I am a � � " I Y t%�!-�i licensed architect or a regisiered professionol engineer AITER � F�r1A� . acting in my protessional mpccity (Seciion 7051, REPAIR � �a�E � � ��� ! ���g W Business and Professions Code). USE OF UEMOL FINAL . EXISIING 6LDG. � BY 'ill� Lic.or Reg.No. Daie /+PPUCANT Te� ��� � . - OWNER-BUiLDER DECIARATION IPRINTI S.MCGiriR15 No.714HFi1231 . i horeby aff�rm�r�ar i��„exempr f.om rhe cootrb�mrs���P�se �ooeess 22900 Golden S rin s Diamond Ba Law for ihe tollowing reasun{Section 7031.5, Business and -1`.. I v �,�� Professions Code1: . PR[sENT � � � Q BUILDING . . . . . . .. . -��i,.'e s�..9 s-c f I, as owner ct Ihe properry, or my�employees with qooRESS � . wages as iheir sole compensaiion,will do ihe work and x�; the structure is not intended or offered for sale(Seciion �OCAUTv j a n[�.�,v� . 7044,�Business and Professions Code). MOVING - TE�- � �- e e a(,' 1 � � I,os owner of ihe propeny,am exclusively coniraciing CONTRACTOR _ NO. �+��V with licensed conirodars b conslr�U Yhe projeci(Ser _ qppRE55 � [7�, I >"�g� � tion 7044,Business qnd Professions Codel. RCQUIRED TOTAL SETBACK FROM FJ(IST. - CONSTRUCTION LENDING AGENCY SET BACK �ARD HWY pROP.I INF W�DTH I hereby affirm that there is�a construction lending ager,y for pgpti�T - - � the performance of ihe work tor which this permit is issued. P.L � (Sec.3097,Civ.C j. SiDE - �- . -�� P.t �endr,r's Name riOriE3 _ _ ?p,C.�ee$ Pcrmit Foe ����� � � ' Lender's Address -! - / � I certify ihat I have read this applicaiion and stoie ihat ihe - Issu re Fee J�`���'�� � o6ove information is correct.I agree to comply with all Counry � I��ves�igaibn Fee �n � � � � �ordinances and Siqte lows relating to building construction, 7oi��l Fee �' --.- qnd hereby oWhorize reorasentat� s of ihis County to eni r � � �pon�bove-meJu}t ahed pr¢ rty far inspection purpo s. - � - � . ts�o.y fl � t .��y�.. � � SEE REVERSE FOR E%PLANATORY LANGUAGE - SiQnalure of Appl�iconi or Fge i ate / . . - �s � � � .n @ � Q � � a -o o n-o m'� m � e� a o � � -n c0� '�' (/f D a ..3�� n � � 0. � E s _ 1 . . 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