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HomeMy WebLinkAbout1516A 1517A (8) � _ _ _ __. _ _ WORKERS'COMPENSATION'DECIARATION �� � � � _ � � i hereby affirm tnat i�have.a�ceriificate of consent to seli ��������'�� ��� ._p�:��'���`� ��.�`��� � G insure,or a certificate-of Workers'Compensation Insurance, p �y, � or a cerhfied copy thereof(Sec..3800,iab.C} COUNTY OF LOS ANGELES BUILDINCs.AND SAFETY � Pol�cµNo 7(�'�G—RllS�ompanY j��� =�d�1�31'�jT �,.. :. - �Cerlified co s hereb fum shed. - BUILDING � PY � F�R APPLICANT TO FILL IN � �i I y�e.�-.�.� a, 'Certified copy is 61ed wiYh fhe muNq Bwldi�g'nspeo- " BWLDING ��80 �22881 �jl].t011 $Qd(� B�.dSa*, 25. ADDRESS � � I �tiondeparfinenL : � - � ADDRESS _� � , � oore ' nPPi��o�r S.McGinnis arr Aiamond Bar ziP 91765 �ocnuTv ---- � CERTiFICATE OF�EXEMPTION FROM WORKERS' NO.OF BLOGS. -� -�. NEAREST . ...,.,.. . . . � .. ' -� '- - - COMPENSATtON INSURANCE � - SiZE OF�07 NOw ON tOi O -�� CR055 Si. :�. � (This secfion;need�not-be completed�if the permit is for one ASSESSOR hund�eddollars($100)or less,) TRA�T 36346 BLOCK LOT NO. MqP BOOK PAGE PARCEL TEL E ZONE 1�P a OWNER [�hmgri OR D2V N � /tCl+��.(.�'� � I certify�fhat in the performgnce of fhe work for which ihis NO. � I permit js�issued,I shall not employ any person n any manner SPECIAL � O. so asto become subject to fhe Workers'Compensation Laws. ADDRESS ], CONDI710N5 _� I ' Irwindale � . CITY Zlp 9�-7�b �� Dafe Applicant � ARCH�TECT OR TEL DISTRICT GROUP TYPE FlRE PROCESSED BY � ' NOTICE�-TO':APPLiCANT.-'�fi after':making.th�s`�Cerfitimte ot ENGiNEEe � �&E��EIig. NpZl3Z545134 � �� �CONST. �� � ZONE . ��j � Exemplion,�-you should-become- subject-�to`the-Workers' . - Compensation provisions of the Labor Code,yo�musi forih- qDDRE55 $2,rj O O BIVd. ZA � i with camply with such provisions or this perm�� shall be � 7EL ��� � � ; deemed revoked. � CONTRACTOR A}ImH.i]SOR Dev. No7148371.27g STATISTICAL CIASS�IFlC.�AyT�lO APT. C DO. .Z ' UCENSED CONTRACTORS DECLARATION � i�� CtA55 NO.�DWELL.�uNirs � �,� i hereby affirmJhat�am licensed under provisions of Chapier 9 AD�RESS 23861 Z,''1 TOTO No. 465b88GB� ' (mmmencing with Seclion 7000)of Division 3 of the Business and ��� SEWER MAP - � � - ' Professions.Code,and my license is in f�ll force and effect. - CRY CLASS -�� -�-� �-� - ���"-� � VAtIDAT10N - � � . . . � . .. ..BK. -.PG. . SQ.FT. NO.OF NO.OP CHECK � ',, License-Num6er LhShRRrur �j�,C�ass�j—], SIZE 8d0 STORIES � FAMILIES �F� ONE , � . �- . `� ` . . . � `-'. .. . .-.. VALUATION � � � �. Contractor �'����Se� ���. Date � � � DESCRIPTION OF WORK -�'��������-����� NEW S f^�� l, . F . . . ADD 4.J �/ �. ❑I am exempt under Sec � C�i�P�R`.TS Q �-- � ` ALTER ; B.&P.C.for ihis reasan REPAIR .❑ . S. - - .� .... �. .._ .. . .___ .' . .�.� `��_b fl Dafei .... USE OF �:a c e� EXIS�ING BIOG. �EMOL ❑ . pj ��-�'� 5�9�ar�,e APP�P N"T No.714861233 FiNa� `'(� t � �G.Lt 9 OWNER-8UlLDER DECLARATION - � � DA7E -� '� _. ''� ,J U . _r. .__ _a. 1 here6y affirm that I am.exempt#rom�the Contractor's license � __ � z Law for fhe following reasorr.(Section 70315, Business ond ""� /+DDRESS ' ' � —� �PINAL - �� �� �" ` � $�y ���.���4'c? � . 'P ��.=-_.. .,,:.;. � ._.:. ..... , _ _ ._ _ ''' ..Professions Code):- :. . . -�-�— PRESENT. . ... . . ... - . � Y � .�,I .� �__�.� _ _`�� �'�l�t. � euaowc I, as owner of ihe property, or my.employees with ADORESS wages as iheir sole compensation,wilf do ihe work and - , � - - -- � � ihe structure is not intended or offered for sale�Section LOCA�ITv . , � 7044,Bosiness and-Professions Code�. � � nnovihl� iet. --= - � �- h � I,as owner of the properfy,am exdusively coniracting CONTRAQOR � NO. . ' �.� J,�',�r1 � with licensed mntractors to construct the projeci($ec- ���-' �- � -� . � . f�n 7044,Business and Professions Code).9 9 y ADRON7 ' ` ` ��3 s e � s '� �. REOUIRED TOTAL SETBACK FROM EXI ___ ._.. . CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.�INE WIDTH -- � � I hereb affirm ihai Ihere is a cansiruction lendin a enc for e �J��,-f j . �the performonce of the wark for which this permii is issued - P.L. - � , (Sec.3097,Civ.C.). � SIDE � . . ... . '`z-. : P.L. , . Q , �., _. �Lender's Name nnna � LDMA Ref.# . J,7�7 9—,�.F WLender's Address - P.C.Fee$ ,.�Q• Permit Fee �. �� ,� > J certify that I have read ihis applicaiion and state.fhai the Issuvnce Fee 6 r�s�) LDMA P/C M .. ._. . Q a6ove information is correci.I agree to comply with al)County Inves�igation Fee / � $ ordinances and Sfafe Iaws relafing to �ding construction, Taiol Fee (� LDMA Perm.R � and here6y authorize represenfatives 1 is Coonty to ente. . , j � � upon ih ove-menti n d properry f r' spection pyfpo� s .. a 4 SEE REVERSE FOR E7(PIANATORY LANGUAGE � t�y�/ � ,�"' Signatu.e of Applimnt or Agent -ote � . _.. OO� z � 0 0 � „ � z V� T tD CD {� (9 Q r-- Q � O N 7 � � O.. p S N � �r j Q N � N Q -�F' � � fl �= (O cfl U � cnp � [n T Cl= Q (D Cr 7 6—. (f] � �� .� fl � =. E. ' 3 j O O S S cQ N Q" � � 'O Q 7 (l 7 � � Q n 9 C7 3 K F '� O �-�^' ° � ^Z X A� � o' roI � � o� vo ? � � ° 1D ,n Q'C N O� Q � Q p � � '< � 3 u'. , , � � J � T O O � O Q Q a � ��O . ��.. � �m I o � � � � O.'� � � . 12/� Q � � o O � < a i~' !a ° " a � � � ' c c = n � � a o- � o- -�i � � ' f�-^,, �, � ° ° � � � ,e.�ro ,e G . �s . �a eo �a G ys N � .... �.. � W .. _.. �. � � b Q O. C C � z H S m� � O A I N . 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