HomeMy WebLinkAbout1514A 1515A � __ __
WORKERS'COMPENSATION DECLARATION -- :--:-. - -� ,�. �. �
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�g i nereoy c"rm rF�cr i �ave a.ier�iiica'e.oY.conseni io seit ������/����� ��.\ �-.Y�,����-��I� ■ ������ ��
msure,or a ceriificate of Workers'Campensation Insurance, j1
or a certified copy�hereof(Sec.3800,�ab.C.) COUNTY OF LOS ANGELES BUILDING:AND SAEETY
: ' , ,
PoiF�q;rvo.7634-81I$ompa�y. Pac. Indemnitv
--=.-Cectifiedm shereb furnished. �- BUIIDING 7� pGi �b�.�Br /�.�C
❑ PY' Y FOR APPLICANT TO PILL fN
AODRESS •'4f-'�2 CJ/
Certified copy s filed with ihe coonty'buiidinq inspec- BUILD�NG �
� � ��on deparrmer,i nooaess��81 22$$1 Hilton Head Blvd �,�J •
Date� �- Applicanf S.MCG1R111S . CITY ' ZIP LOCALITV �
� CERTIFICATE OF EXEMPTION FROM WORKERS' �� - NO.oF BLDGS. � Nea,aesi .. _,.__. . ....._. .. .
� -COMPENSASION INSURANCE ': -;-�� � S¢e OF i01 NOW oN ioi CRoss 57. .:
(TNis section need�noi-6e completed if the permrt is for�one ASSESSOR
hundred dollars($700)or.less.) � TRACT b�OCK LOT NO. MAP BOOK PAGE PARCEL �
� owrveR Ahmanson Dev. N�18 8 14 7 15 2 use zoNe r�nnP ` _ `
Lcerlify that.in the performanta ot ihe work for wRich��this NO. (i 3 ���.
permit is issued,I shall not employ any person in any monner � SPECIAL - 'd
so,as to become sobjecf to ihe Wo�kers'Campensation Laws. � ADDRESS].00Z �COffiID2TC2 1JI'. �� � - � �� CONDITIONS �v
� aTv Irwindale ZiP 91706 �
�ate App�icant
NOTICE TO'APPUCANT �If, ofier makin this-Cerfificafe of pRCHITECT OR TEL �ISTRICT GROUP NPE FIRE PROCESSED BY ��,o
� s ENciNEER B&E Eng. Na132545134
Exemptian, you should become svbjeci to�the�Workers' � CONSL ZONE {�
Compensation poovisions�of ihe Labo�Code;you must forih- qDORESS , �� � '6�.
� with comply witk�such provisions or Ihis�permit shali be . . ._ yl
I deemed revoked T srarisricni cu,ssiFicn oN nar. oo. `Z
- CONTRAQOR Ahmanson Dev. �148371279 —
LiCENSED CONTRACTORS DECLARAiION � i�� C�nss No. oweu,uNiTS �
I hereby affirm)hot I om licensed under provisions of Chapfer9 - ADDRE55 Z3H61 �l TOYO NO.t}Ejj(]$$(�$C�
(wmmencing wiih Section 7000)of Drnsion 3 of fhe Business ond �-= SEWER MAP "*�-�:-�
El Toro ��� B-1
Professions Code,and my license�s m ful�l force and effect. CITY CLASS -� ' ���VALI�ATION '
. i . . . . . SQ.FT. NO.OF NO.OF CHECK . BK. PG. . ..
I ��censeNumber lihShRR(3R!' l,c.Class #�-j , sizE StORies FAMILIES oNe
- � ` VAIUATION
DESCRIPTION OF WpRK� ����§]' -NEW 5 �
I Contractor ���e„ 7�z.��., Date ,.. .. . . . . .
❑I am exempt under Sec. CE:RPORTS AOD Q
ALTER
. �
! 8.8P.C.for fhis reason .REPAIR ❑ S . .�. -. '� c�i ��,�t��� .
I Date: � � USE OF DEMOI ❑ �
'� � � EXISTING BLDG. " .jf g..a �.��.� , .
� $ignafwe APP�ICANi TEL - ::
�.� OWNER-BUILDER DECLARATION PRiNT S.MCG1riR1S No7148612311 DA E� '�"�.�",y�� -..-.� - ...........t. .e.?�(�:� '
_. _
--I hereby affirm ihat I am exempt from the Coniractor's License � , �'
Law tor the following reoson:(Section 7031.5, Bus�ness and .4DDRESS 22900 GO�.C1flII S Tln 5 D1aIllORd Bax' p�ryp� -. - � '-�� . ; , ` 4� T' �
-Pro#essions Codej: . . .. -- �PRESENT"�.... . . 8Y _f'q,�_ ,��� a ro �3;
❑ BUILDING 6 �.
I, as owner of the property, or my employees with ADDRE55 J 7.� Q"�`�'i`j
wages as iheir sole compens�tion,will do ihe work and � , -� �� �- �-� �
the structure is not iroended or offered for sale(Section LOCAUTY � ,
� 7044,Business and Professions Code). MOVING TEl � - --. �--
� I,as owner of ihe properly,am ezclusive�y coniracfing CONTRACTOR NO. . , ,
with licensed coniractors to construct ihe project(Seo- � � � ��-=�7-�i��.�i .
tion 7D44,8osiness and Prafessions Code). ADDRE55 u _
- � REQUIRED TOTAL SETBACK FRO I T. � � h`,g '� '� �' ° �
CONSTRUCiION LENDIN6 AGENCY - SET BACK YAR� HWY ppOP.LME WIDTH � � �-�
I here6y affirm�hat ihere is a construction lending agen<y for fRONT � . .�`�� �f�g,7� �
ihe performance of ihe-work-for which ihis permit�is issued P.L � �- - � . . _ ._�_. _._,. _ ._... _ ...:
(Sec.3097,Civ.C.). SIDE � .
none P.i. f #._�5��
lander's Name ����4 "�� '
< -'-:
m -. . `. .,.. RC.fee$ � Permit Fee V /-� LDMA Ref.H . : �J I i g"'"��J� ..-
Lender's Address � _ ` , � �
1 certify thaf I have read this application.and state ihot the Issunnce Fee `�S� LDMA P/C# �
Q above information is wrrect.I agree to comply with all CouMy Invesii afion Fee /�/'� �(
ordinances and Stafe laws relating to building construction, 9 To1al Fee `�j` �"� LDMA Perm.k
and hereby aoihorize representa of ihis Caunty to entt,,�er
a upo�above- tione�o erty or inspeciion urp��,,�,,[["" . ` .
o ��s����___,?�y/ y SEE REVERSE POR EXPlpNA70RY tANGUAGE :
Signafure.f Applicant or Agent 9��� . � .. �- ... .. . .._�7 i