HomeMy WebLinkAbout1518A 1519A (8) 9 WORKERS'COMPENSATION��ECIARATION - � � . . . �
� I.hereby pH�rm thpl I have a,certifiwte of mnsent So self I'
. msore,oracertificateofWorkers'Compensation,ns�.an�e, �APPLICAT(QN FOR .BUILDING�� PERM1� C�
I or 6 cer�ifiad copy thereof(Sec se00,Lab:C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
�� Policy No. 7h�L�—Rl g�rnpany�Q� Tnr�amni ty - BUILDING l� �N [p_ p '
� Ce�iified copy��s hereby fumished. FOR APPLICANT TO FILL IN ADDRESS �.2-eQ�r {�^c�Y�+�- `�-e.._<>L
7 1-t Certi4ied mpy is filed�wi1H_the�county building'inspeo- gU1L�ING
� ��i r�o�dePa�rme�� nooaess �k79 22881 Hilton Head B1dg. 25 ��J�j•
� Date AppiicanY S.MC�ilIIR1S CI7V � ZIP LOCALITY ��
s " -CERTIFICATE OF EXEMPTION FROM WORKERS� � � � - -�No.oF e�o�5. - �- NFAREST � - - �. � - � . - �
g ' � � � COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT � CROSS ST. ���
� (Thirsecfion need not-�be compieted�if the permif�is'forone ASSESSOR
j hundred.dollors($100)oc less..) , . . - TRACT (� B�OCK lOT NO. MAP BOOK _ PAGE PARCEL
g TEL USE ZONE �P
� owNeR Ahmanson llev. rvc$18$147152
I cartify-that in ihe-performante of the�work for�whick this N�� a
p permiS is issued,I shalf nof employ any person in any manner _ - . SPECIAL
5 s6as90 become�su6jed to'fhe Workers"-Compensation.Laws. � "ADDRESS - CONDITIONS V
� < ,, .,,, ,. aTv Irwindale ziP 917Q6 �
Date ApplicanT" . .�
NOTICE�TO APPIICART: If,��-�❑ffer makin this Certificafe of ARCHITECT OR TEL OISTRICT GROUP TYPE FIRE PROCESSED BY � .��
f g ENC�INEER B&E EnP-�. NO?1325�FS�-3tF- CONST. ZONE -6�
C Exemption, you shouid become subject to the Workers' W
Compensation provisions of�ihe LoboeCode,you mus�for�h- � qpDRESS �Z.j CO�pTaL�O B7.VC1. T,A y0��+�. �� G .a
with comply-�wifh-such.provisions or this permit shall be - y
{ deemed revoked. �.. ' .. TE�� STATISTICAL CLASSIFICATIO APT. NUO. �
F I.ICENSED CONTRACTORS DECLARATION � -_ coNrRacioR A son Dev. N 7.4837 2 —� .
��� � � CLASS NO. �-` �WELi.UNI75
1 hereby aEfirm ihot t om licensed under provisions of Chapter 9 ADDRE55 NO. �� �F6rJ�7 . '
�
(commencing with Section 7000)of Division 3 of the Business and ��� SEWER MAP �
! Professions Code,and my Iicense is in full force and effect. CITY El Toro nAss — eK � VALIDATION
' 465688GBC so.Fr. rvo.oF No.oF cHECK
{ L�cense Number � Lic.Class�-�-8—�- SIZE STORIES fAMILIES ONE i � . � .
E AYlID2RS011 DC'V. DESCRIPTIONOFWORK ������� NEW � ' VALUAITIOIy„ ,
( Coniractor Dafe ADD � "t':S �"��> 5���,U H .. .
❑I am exempi vnder Sec. CARPORTS ALTER � , ¢' a��j �
� B.&P.C.for this reason �� REPAIR � S T' e e,i . � _ .
Date: USE OF � � G�'
iE%ISTING BIDG. DEMOL y _ n
Signafure APPLICANT TEL. FINAI ` 1 0 � �`�`y C`7� .
; OWNER-BUILDER DECLARATION PRiNi S.MCGlAri15 NO 14 Z� pAfE c�y. ��?1 ,_ , ,
i bhereby�affirm thaf I am exempt from the Conlractor's.License � i�`� �'� � g���'�
22900 Golden S rin s Diamond Ba .
Law�foi fhe follow�nq reason:(Sedian 7031.5, Business and � ADDRE55 � � - FINAL"'�� -
__ '
'Protessibns Code): . ".... . ..� ... . ... . ...` PRESEM____.— __—_._—. _ _ . —_ —__— _' ��BY 4nv'�.`��-' -. ..-__: _. ... .W. _.. _ �.
�, ❑ BUILDING - . - _ . :. - .
i, as owner of the properly, or my employees with ADDRESS
I wages as their sole tompensation,will do ihe work and - �-
�, the siructure is nof intended or offered for sale(Section -� LOCAUTV , , , „� �.� 9�
G �
�- � --704d,BusFrress and-ProfessionsCode): - � - --- -MOVING� - - -TEL � - - � ----- -���� � -
CONTRACTOR NO.
� I,as owner of the property,am ezclusively contracYing �: i`o a a m '��-'��
� with licensed coniracrors lo conslrucY the projact(Sec- qoDRE55 �
tion 7044,Bosiness and Professions Code). ' - ; � a m(���;�'7 J ..
REQUIRE� TOTAL SETBAIX FR I T. -.. - _
�CONSTRUCTION LEN�ING�AGENCY ��� - $ET BACK WARD HWY pROP.LINE Vd�DTH - � ;
I here6y affirm that ihere is a consiruction ler.ding agency for PNON7 � �'� ��'�������
the-performonce o4 the wor�k for which fhis permit is issued P.L � - -- - � . -
(Sec.3097,Civ.C.). SiDe � G� i 4"`�;J -�
m _ none _ v.i._--.
____ :_. __
Lendei s Nama -
o� ' tDMA Ref.# ,. ' .. . '
� Lender's Address � - P.C.Fee$ ��' Perm t Fee �J•��� : � � - , � - -
w 1 certif that I have read ihis a limtion and state ihat ihe f � . ,_ � ��� '� �
� Y PP - - - �issuance Pee - (I�� �—LDMA-P/C# --. .-.-- - - -. ...
Q a6ove informafion is correct.i agree to mmply with alI County Invesegaiion Fee -�7(
ordinances and State laws relating to building mnsiruction, Toral Fee ��' I J` LDMA Perm.N � � - - �'���
and hereby authorize re resentative of ihis County to enf ,
m upon th ove ment' d prop tr f Jinspeclion parpos . .
Q �
^ � f'"✓'i-- �'' �.�� SEE REVERSE FOR EXPLANATORY IANCUAGE
igmmre of Applimm or Agent �e ' � � - -� � ���
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