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
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