HomeMy WebLinkAbout1512A 1513A (8)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a, certificate of consent to self
insure, -or a certificate of Workers' Compensation Insurance,
or a certified copyahereof (Sec. 3800, Lab. C.)
Policy No. 7F,�L. Rllf�ompony gaB�
�.: Certified copy -.is hereby: furnished.
Ei Certifiedcopy is filed, with the county-botfdfng ms'pec-
'tion department.
DateApplicant S.Me GinniS
'-CERTIFICATE OF EXEMPTION FROM WORKERS' -
-' ---
COMPENSATION INSURANCE `
(This section need not be completed if the permit, is for one
hundred dollars ($100) or less.)
I. certify that. in the performance of the work for which this
permif is issued, I shall not employ any person in any manner
so ci.,tp becomesubjectto the Workers',CompensaTion Laws.
Date Applicant
NOTICE; -TO APPLICANT: If; after making this Certificate of
Exemption, -you should become subject to the Workers'
Compensation provisions•of the Labor Code, you, must -forth-
with comply with such provisions or this•permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions.Code, -and my license is -in. full force and effect.
License Number 465688CRC Lic:: Class A-1.
Contractor Ahmanson DCV.. Date
❑ I am exempt under Sec.
8.8P.C. for this reason
Dote:
OWNER -BUILDER DECLARATION
- I hereby affirm that I am exempt from the Contractor's License
Law for the following: reason (Section 7031.5, Business and
_.Professions Code): -
I, as owner of the property, or my employees with
ages as their sole compensation, will clothe work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for
theperformanceof the work for which this permit is issued
(Sec. 3097, Civ. C.).
none
Lender's Name
Lender's Address
I certify that I haveread this application and state that the
above information is correct. I agree to comply with all County
ordinances and State lows relating to building construction,
and hereby authorize representatives of this County to a ter
upon the ve-mentior�e rope, or inspectio pure es.
Signa u eof Apph—, ., A int /Date ,
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING.,AND SAFETY
J
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
- .....
ADDRESS #82 " 22881 Hilton Head Bldg, 25
CITY Diamond Bar ZIP
LOCALITY
" NO. OF BLDGS.cIA&APBOOK
NEAREST - - --"
- --
SIZE OF LOT NOW ON LOT 0
CROSS ST. -
-
ASSESSOR
TRACT BLOCK COT NO.
PAGE
I PARCEL
_ TEL.
OWNER NO.
USE ZONE -.
OP
Y'
'- ADDRESS 1001 Commerce-- Dr. - -- _ _
SPECIAL
CONDITIONS
Irwindale
CITY zIP91706
-_ ARCHITECT OR TEL
ENGINEER ME Eng. N021325
DISTRICT
/
1
GROUP
TYPE
CONST.
FIRE
ZONE
PROCESSED BY
7
ADDRESS H 825 Colorado Blvd. LA 90041
CONTRACTOR Ahmanson Dev. T
_ N�748371279
STATISTICAL CLASSIFICATION V
- CLASS NO. DWELL UNITS
APL
- UC
- ADDRESS 23861 El Toro No. 4651-
LIC.
SEWER MAP
'. CITY El TOMO CLASS B- 1,
BK
VALIDATION -
. -
SQ. FT. NO. OF NO. OF
CHECK
_
.SIZE STORIES FAMILIES 4
ONE
_
- - VALUATION
- -
-
_
DESCRIPTION OF WORK
NEW
$ --f7� C,.'1
P (v i
CARPORTS
ADD
1 5- i. '2� A .
ALTER
-
REPAIR,
$
r e ct a e 1
USE OF
EXISTING BLDG.
DEMOL u
p
FINAL 3 I,.
--DATE
- - -
f' e c 14 (j, 4 1i ..
),I • "'
APPLICANT TEL.
- (PRINT) S.MCGinnis IN
ADDRESS -
r- FINALu.8
5
PRESENT
-. BUILDING
BT
--
ADDRESS
,
-
-
v 13 A -.
-
LOCALITY
MOVING TEL.
CONTRACTOR NO.
) e -6 11. 7 ,? -
6-117.5T5
d..r/, 3 4 — &5
-
ADDRESS;
REQUIRED TOTAL SETBACK FROM
- SETBACK YARD HWY PROP. LINE WIDTH
FRONT - - P. L.
SIDE
P.L.
LDMA Ref. It
t... ,..
.. --
`--�
Tj `,� o^
-
Pet Fee :d 7-4
P.C. Fee $ O r rm
J
r;
I--
Issuance Fee a " "
LDMA P/C #
-
Investigation Fee !
7S"Totoi Fee �p
LDMA Perm. #
- -
SEE REVERSE FOR EXPLANATORY LANGUAGE
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