HomeMy WebLinkAbout1532A 1533A (8) � WORKERS'COMPENSATION DECLARATION � � '� : �
� he�eaY a,f��m ,�a,� ha��a certifimte of consem to 5e�f APPLICATION F4R BUILDtNG PERMIT �
k insure,or a certificofe of WorkeFs'Compensation Insurance, .
or a cerrified wpy thereof�Sec.3800,�a6.C) ` COUNTY OF LOS ANGELES BUII�ING AND SAFETY
P❑ol�cyNon7tiZ/��PAI'tACompany ���C.r�.e.���y BUILDING �� // !/,F? Il F
Certified copy is hereby fumished POR APPLICANT TO FILL IN qooeess � /�4"t-'L'e'�- F���-x�c.
� _ __
Certi ie copy is i ed wit fhe county building inspec- �BUiLDING
tiondeportment. � � AODRESS �183 22881 I3ilton Hea B •��
oo�e apprmm S.McGinnis �iT� Diamond Bar ziP 91765 �ocnurv
� CERTIfICATE OF EXEMPTION FROM WORKERS� � NO.oF etocs. �:. NEARESi......�..i ..... �_� ...._...... .... : . . .. .� .
- � COMPENSATION INSURANCE - SIZE OP LOT NOw ON LOT �- CRO55 ST. - � -
(This�section�need not�6e completed if the permitis#orone ASSESSOR
hundred dollars($100�o��.less.) TRAcr36346 BLOCK LOT NO. Mp,p gOOK PAGE PARCEL
_ _
'�' " OWNER �1�1I[12.RSOR vEV. Nc�issz4�152 ��ZONE�- PAAP .�,` � ��r/� - �
I�ceviify that in ihe performance of ihe work forwhich'�ihis NO. � 7'�'�Y! 'y
permit is issued,I shall noi employ any persOn in any manner = �------�-�-�� SPECIAL �� � - - � - �-�A.
so as to become subject to�fhe Workers'.Compensation'Laws. .4DDftE5S-I;Q�}- �COI[IItIBTC2-DT. - CONOITIONS =0
cirr Irwindale ZiP91706 u
Date ApplicaN - -. -_ _. ��
ARCHITECT OR TEL ; - �O
NOTIGE�TO"APPCICANT: 1{;'ofter mokin ihis Ceriificate of DISTRICT GROUP TYPE PIRE PROCES$ED BY
9 ENGINEER St4E �Gri N�13ZS�+S1.3�F�� � �i'
Exemption,�you should become subject b ihe�Workers' �conlsi. � ZONE ,�
Compensation provisions of fhe labor Code,you must forih- �Q 'L ;;d
with-comply,.-wi1H��such�provisions or this permit shall 6e E+�DRESS 2 ,n . N
deemed revoked. . , � Tr�� STATISTICAL CULSSIFICATIO APT. NDO. � -.:�
� CONTRACTOR NO
LICENSE�CONTRACTORS DECLARATION�� �� �IC. - CLA55 NO. DWELL UNITS
I hereby affirm rhat I am licensed onder provisions of Chapter 9 qo�RE55 tv0.
{commencing with$ection 7000)of Division 3 of the 8�siaess and ��� r SEWER MAP
Professions Code,and my license is in full force and effed. CiiV E�.. TOTO CLA55 B-�- VALIDATION
� SQ.Ft. NO.OF NO.OF CHECK ' BK� �'� � �
License Num6er� 4f7S6ggC�(. '�Lic.Class�R-l'- �� SIZE- �$Q �STORIES� FAMILIES ONE ��. _ . . -
Ahmanson Dev. - oesce�arioN oF woR�c���X��nY�i� New � � u 3.2 A
Contracror Date S S�(J�7 .-i
CARPORTS noo � n Q � °t
�I am ezempt under Sec -� � - ����-� � ����
, .... ALTER � 1 �' �v V�4� �
B.&P.C.�for thi5 rea5on REPAIR S ' "�- �� "" "�
� Date: usE oF -� s, g .,�l`/i C3?
� EXISTING BLDG. �EMOL ❑ � .
Signatore : ^PP'R,NNjS.MCGINNIS No 714861232 FiNAI ,�' �� L: I I S,"85
DWNER-Bt11L�ER DECLARATION ..,., DATE �' �----- -� -� ��..•--�:.-
d,hereby affirm ihat I am ezempt from ihe Conhactor's License 22900 Golden $ Tj.11 S I71dIDORd B8 - � �
Law for the foflowing reason'(Section 7031.5, Business and ADORE55 p $ p�Np[- -� f� �i � ' �" ' �� .
Professions Code): � ,..._ PRESENT-----_..--------.._.--�------- _ `-...By �`��(,1nsC.tG�>,--� - _ ..}>: . _ ..
� I, as owner of the property, or my employees with. A�DR 55 . ��
wages as thev sole mmpensotian,will do the work and _ -. �� .�i ;.5 h' �
the str�cfure is not iMended or offered for sole($ection -� �OCALITY �,-�. : ��
7044,Bu5inessandProfessionsCode). ' .. .`- MOVING. ... ..' .`.. ... .'...."TEL... ..-..-. .-_.... '",.. . -.. -.. � ..�.. -.. �-. �...�. e. �, tr�a�"� "^ .
OCONTRACTOR NO. . �� - + '��
I,os owner of the property,am exdusively coniracting` , _ �;
with licensed contraciors to consiruc}ihe projeci(Sec qDDRE55 �� � ��.���ry a� ��•��t�J � �
tion 7044,Business ond Professions Code). . . _
CONSTRUCTIONLENDINGAGENCY SE�BACK YARD Hwv i�TApROP.LME WioiH � - ' , " '�'�-I�.����Jz����'
I hereby affirm that ihere is a wnstrudion lending agency for �PRONT � � .�7 .� ��W�,a
ihe performance of ihe work for which this permit is issued �P.L - - � `
(Sec 3097,Civ.C.). � SIOE � `
nane c.i. ..
lender's Name �� -
� LDMA Ref.# - -� � -
=� Lender's Address P.C.Fee$ ��^"� Permit Fee �h �' -► .
y �f� k-
I cerfify that I have read this applicatipn ond state ihat fhe Issuan<e Pee �� `'" �LDMF+P/C# ' � �
¢ a6ove information is correct.I agree ro comply with all County Investigation Fee -7 -
� ordinances and State laws relating to huilding ronsiruction, Toml Fee ��' /�9 LDMA Perm.H - � �
❑nd hereby authorize represent � s of ihis County to nter � - ;���
a upon ihe ove-menf d p_ ert for inspec�pu oses. � � , y,.
a 4.t�Q�. � SEE REVERSE FOR EXPLANATORY LANGUAGE � �
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