HomeMy WebLinkAbout1516A 1517AC WORKERS' COMPENSATIONDECLARATION
BLlJLDI G PERMIT J1
BUILDING;.AND SAFETY
I hereby affirm that f have. a certificate of consent to self
BUILDING
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I insure, or a certificateofWorkers' Compensation Insurance,
ior a certified copy thereof (Sec. ,3800, Lab. C.)
ADDRESS
Policy,No 7(n'RG-8j l Siompany PaC =PdoJPJQi tyT
� Cerhfied copy is hereby furnished. - -
�
IPIPIP
Q, 'Certified copy is filed with the county building mspec-
BUILDING
tion department.
ADDRES'
Date Applicant S.McGinnis-
CITY
CERTIFICATE OF EXEMPTION FROM WORKERS'
NEAREST ... .. ...,,...
- ' - - - COMPENSATION INSURANCE -
SIZE OF I
(This section ;need not be completed if the permit is for one
CROSS ST.
hundred dollars ($100) or less,)
TRACT
I cerfify that in the performance of the work for which this
OWNER
permit js issued, I shall not employ any person n any manner
so alto become subject to the Workers' Compensation Laws.
- -
ADDRESS
Date Applicant
CITY
a NOTICE TO 'APPLICANT: -1f; after.makingthis`Certificate of
ARCHtTB
Exemption, you should- become' subject-, to the -Workers'
ENGINEE
j p
Compensation revisions of the Labor Code,
p you must forth -
ADDRESS
with comply with such provisions or this permit shall be
TrWindale ZIP 91706
deemed revoked.
CONTRA
' LICENSED CONTRACTORS DECLARATION
TOR B&E Eng. TN,�132545134'
I hereby affirm. that I am licensed under provisions of Chapter 9
ADDRESS
(commencing with Section 70D0) of Division 3 of the Business and
Professions. Code, and my license is in full force and effect.
- ,-
- CRY
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W
SO. FT.
j LicenseNumberLh ShRR(]R!' Lic. Classes -j,
SIZE
- Date
ContractorDtzu-.
��kTRgi169L1
DESCRIPT
�1 am exempt under Sec.
APT. C DO.
BAP.C. for this reason
LIC.
23861 El Toro No. 4656880B
Date: -
USE OF
EXISTING
- "Signature -
APPLICAt
OWNER -BUILDER DECLARATION
PRIN
1 hereby affirm that I am.exempt from the Contractor's License
VALIDATION
Law for the following reason :(Section 7031.5, Business and ""
ADDRESS
Professions Code):--- "" -- -- —
PRESENT
I, as owner of the property, or my employees with
BUILDINCADDRESS
wages as their sole compensation, wilt do the work and
the structure is not intended or offered for sale (Section
LOCALITY
7044, Business and Professions Code).
MOVING
I, as owner of the property, am exclusively contracting
CONTRA(
with licensed contractors to construct the project (Sec-
I 5 i, b A
tion 7044, Business and Professions Code).
ADDRESS
CONSTRUCTION LENDING AGENCY
REOUIR
SET BA(
I hereby affirm that there is a construction lending agency far
FRONT
the performance of the work for which this permit is issued
P. L.
(Sec. 3097, Civ. C.).
SIDE
DATE
P.L.
Lender's Nome none -
. '.
W Lender's Address
P.C. Fee
I certify that I have read this application and state: that the
n above information is correct. I agree to comply with all County
Invesligal
$ ordinances and State laws relating to construction,
TEL
11 and hereby authorize representatives 1 is County t.,el
is ent
Upon iheve-menti n d propertzfspectio" pyfpo
a
FOR NO,
1 5 1, 7 A
Signature of Applicant or Agent -ate
APPLICATION FOR
COUNTY OF LOS ANGELES
BLlJLDI G PERMIT J1
BUILDING;.AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
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ADDRESS
1180 22881 Hilton Head Bldg. 25
�
Diamond Bar ZIP 91765
LOCALITY
NO. OF BLOGS.- -r.
NEAREST ... .. ...,,...
)T NOW ON LOT U
CROSS ST.
36346 BLOCK LOT NO.
ASSESSOR
MAP BOOK PAGE
PARCEL
TEL.
Ahmanson Dev, N
�,qE ZONE MAP
1001 Commerce Dr.CONDITIONS
O
TrWindale ZIP 91706
W
TOR B&E Eng. TN,�132545134'
DISTRICT GROUP TYPE
FIRE PROCESSED BY
CONST.
ZONE
V
W
825 Colorado Blvd. LA
d
L
TOR Ahmanson Dev. No7148371279
TN(L)7148371
STATISTICAL CIASSIFICATIO
!!JJ ryry
CLASS NO. DWELL. UNITS
APT. C DO.
. Z
LIC.
23861 El Toro No. 4656880B
LIG
SEWER MAP -
Ll ;oro CLASS -
- -- - _-
BK. PG.
VALIDATION
`-
NO. OF NO, OF CHECK
800 STORIES 1,AMILIES 4 ONE
DN OF WORK ->�� ' NEW
VALUATION r
3 -
,a,7
ADD
CARPORTS
$ W
ALTER ❑
REPAIR .❑
_ $ - - - _- .._ : .__'.
I 5 i, b A
dLOG. DEMOL ❑
pj a c e e. 2 1
I TEL
714861231
FINAL `' (�
t �' G 4 9
-
_.,
DATE
. '.
.FINAL .. .—
x
sy a{) rr 9By
0719— 5
TEL
FOR NO,
1 5 1, 7 A
YARD HWY TOTALPSETBROP. NCEFROM WEXI
IDTH-
)a®61,75
-
0,7, 1 9 --F
�j
® Permit Fee . �C
..7-
',1
LDMA Ref. #
-
Issuance Fee d 'sv
LDMA P/C #
-.- -
>n Fee
Talal Fee (a s `
LDMA Perm. #
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SEE REVERSE FOR EXPLANATORY LANGUAGE _
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