HomeMy WebLinkAbout1538A 1539A (9) � , _
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' WORKERS'COMPENSATION DECLARATION � - � n
� �nsureborafcertifca'idotWokersr�Compensa;o�s��s��Q�e" AP�P��LICATI�ON F�Q-R BUI�L:DI��NG.���PERMIT �
� br a ce�t�fied copy.-theieof(Secr 3800;�ab:C} -- COUNTY OF LOS ANGELES BUILDING AND SAfETY
Pa�Y No 7634-8k�8,��y Pac. Indemnity suaoiNc r� /j /)�-- ?i �
.:Certified�copy>is hereby:fur shed.�•����-� FOR APPLICANT TO FILL W� qo�ResS °��t�� f`r+--��`�'� f"�'���-
�'`,-f�. "cernfied copy�s f�led witH}he county buiiding��speo- euaoiNc �k78 Zzggl Hilton Aead llr.Bldg. / ,p
� YY��lTon departrnent. - ' �� � � ADDRESS /1. ��
�:. Daie Appiicant S.i�CCi1llt11S � CITY ' ZIP LOCALITY -
� ' - `CERTIfICATE OF EXEMPTION FROM WORKERS'--���`�� � �� NO.OF BtDGS !�. NenRe57 � . �_-�-� � - � �..�� �.�- .
I . .. SIZE OF LOT NOW ON LOT � � CRO55 ST. - � �
� COMPENSATIONINSURANCE -
� (This-section need not be completed if ihe-perrtiif is for one TRACT 6346 bLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars($100)or less.). :
! owNee ��nson Dev. N�.818814715 use zorve tiwP �' �
, I certify_ihat in the performance of the work for which�ihis . NO. ��'' �{'� �
j permrt is issued,I shall nof employ any person m any manner : -� SPFCIAI �
� sa as to becoma subjecf to ihe Workers'Compensation�laws ����- ADDRE55� -].00l��CO211II12TCE"�"�DT. � """���� -"�" CONDITIONS -�
I " arr Irwindale 71P 91746 �
iDafe...... ,..�. A'pp�icani'. ......,, ..,. ,. � . - ' O
j NOTICE�TO APPLICANT� If,�-after making�this Certificate of ARCHI7ECT OR TEL. DISTRIQ GROUP NPE fIRE PROCESSED BY �.
'� Ezempiion, you should become sub�ecf-10 fhe Workers' ENGINEER &$ NU CONST. ZONE ��'V
�1
:' Compensation-prowsionsot-rhe Labor�Code,you�.most forth- 8 V LE� � 1 ��"' � ��� �'
, with comply witH-such-provisions or ihis permit shall be ...- ADDRESS N
� � 1EL STATISTICAI CLASSIFlCATION APT. NDO. - Z
deemed.evoked. coNreacroR Ahman on Dev. No, 1 8 2
� LICENSED CONTRACTORS DECLARATION� . � ���_ � CLA55 NO. DWELL UNITS
�, !hereby affirm that I am licensed under provisions of Chapter 9 nooae55 23g61 EZ TOTo No. 4656ascs �
i (commencing�with$ection 7000)of Division 3 of ihe Bosiness and ��� SEWEk MAP "
'�. Professions Code,and-,my license is�in4ull�force and effed. CI7V Ei Toro CtA55 B-1 BK � �. YALIDATION �
�. -- S4.FT NO.OF NO.Of CHECK - - � � �
L[cense Numtier �+E�SFi88GBC Lic,Class B-1 S�ze c�3�� STOR�Es FnM�uEs �+ oNe '
-� ' � ._.VALUATION .. . � . - �s�:F
Coniracio� Ahman9cli7 D2VDate �:: �ESCRIPTION OF WORK �`����',����� NEW � --_.; �5� + - `f . �
� CARPORTS ADD �' �f�
�I am exempt under Sec. � , 4r� � � ��. �
. . . . . __ :_... -.. .-� AUER ❑ . i G Q:,C�!-� .
B.&P.C.for this reason _ REpqiR..O � S . . -. :
Dafe: -� EXISTOING BLDG. DEMOL .' �.�i�,`,C}..ry �..
Signafure . . ..._. APPIICANT , , TEl FINAL � o r;
aRiNr�S.McGinnis No7148612311 �� i G% 9 u
OWNER-BUILDER�ECIARATION � DATE �.� �� - �--�- �- --� --�
�I hereby affirm ihat I am exempt from the Coniracror's License � .. ..
�aw fo�rne following reoson{Section 7037.5,Business and AODRE55 22900 Golden S rin s Diamond Ba FlNa� /' '" -'`
'Professions Code)�'-_ . .. .: .. .... .. . . _.--` pkeSeNi .. . . .. gY �y?.+,,t.!>-t,x-' '-_ _ . :
QBUILD�NG . s � v g(�u ,
1, as owner of ihe property, or my empioyees with ADDRESS
wages as their sole compensation,�will do�he work and � . � _ �
IOCALITY , � t' '�'
the structure is not intended or offered for sale(Sedion �� . n-° � n °�g'�(
70-04,Business and Professions Code). �� � � MOVING � �� � �-'TEL.� � -� ��' �- - � � � ��
� I,as owner of the property,am exdusively mnirocting � CONTRACTOR NO. � i e u�(�� �v �..
with licensed coniractors to mnstruct ihe project(Seo- qDDRESS �
tion 7044,Business and Professions Code). . , � ° � '�,��: _.,
REQUIRED TOTAL SETBACK FROM -EXI T..
� � � CONSTRUCTION LENDMG AGENCY � � � S�i BqCK YARD r+wr pROa.uNE wioTH � � C 1 j �j-�fj,j
1 hereby affirm that there is a consiruction lending agen<y for FRON7 - �
fhe performance of the work for which Ihis permit is issued - P.L . - -�,-� - -� -
(Sec.3097,Civ.C.). SIOE . - � �
P.L. . � _ ......,..
lender's Name nOne - -
( / IOMA Ref.# - ' �� "
W Lender'S Ad[lress - P.C.Fee$ `��= Pe.m-�FeP *J -� ' . .
>
i certify that I have read this applimlion ond stale ihat the . Issuance Fee �� �� L�MA P/C# � -�
¢ above information is mrreci.I agree ro compiy with all County Imestigation fee / . �.
g ordinances and State laws relafing to building consirutlion, Total Fee O I"f��� L�MA Perm,p � - -
and hereby auihorize representatives of this County to en r . � � .
� upon t bove-me ti ed pro r� r inspection�porp es. .
a __� �. � � : . . ,_... .
SEEREVERSEfOREXPLANATORYLANGUAGE
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