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HomeMy WebLinkAbout1534A 1535A (8) � WORKERS'COMPENSATION�DECLARATION �� � n �� 4 I-he�c�y�tirm thot I'riove a�cerii'timfe of conseni fo seli A�PL1-�A�.�ON �O� BUIL��DING-��.PERMIT - ��; � insoFe,or a certifiwte of Wo�kers'Compensatian Jnsurance, . . � or a certified copy thereof($ec.3800,Lab.C.) � � ��� � �� COUNTY OF LOS ANGELES BUILDING AND SAFETY � Policy No JE>3�+-S�CySipa y Pa rnd m � v � - � Cerhfied m s-hereb fuc shed � . � BUILOING p) � /J � � Pv� v FOR APPLICANT TO�ILL IN ADDRE55 �Z�'�SFl thJ� l��G � (-1�� Certified copy is tiled with the county build�ng mspeo BUILDING � �!q �ZS�� tion department ADDRE55 ��86 ZZ8�.5 ��l.lt0 . 2d �.� . 2 ✓1-�J�. 8 Dafe Appiicant S_M�C;innic CITY ZIP LOCALITY � - CERTIPICATE OF EXEMPTION PROM WORKERS'- � NO.OF BL�GS. �- NEAREST . . . . ...._ . -COMPENSATION INSURANCE � S¢e oF�Oi NOW ON ioi O +� CRO55 Si. (This section.need_noi be��.completed if fhe permit is�for one � A55ESSOR hundred dollars($lOQ)or less.) TRACT 36346 BLOCK �OT NO. MAP BOOK PAGE PARCEL OWNER Ahmanson Bev.� N�1881�+7152 USE ZONE nna.P � � �� �_� ,/ . � � ',�� i certify that in�he performance o�ihe work for wfiich this NO. permit is issued,I shall not empioy any person in ony�manner sPECIAL so�os to become su6jeU to fhe Workers'Compensationlaws. ADDRESS 1� O 2 CONDITIONS �,,� arv Irwindale zip 9170h �� � Dqte Applimm �� � �� NOTICE TO APPUCAN7. if, afler.making this Certificdte of ARCHITECTOR NOZ Z 1 DISTRIQ GROUP TYPE FlRE PRO�ESSEDBY Exemption,��you should become�subjett to the Workers' ENGiNEER CONST. ZONE ,� � Compensahon provisions'a4 ihe Lpbor Code,you�musf forih- qDORE55 $25 Colora O BZ.V . LE: 9 � 1 �� a `� � with comply ih-such_-provisions or this._permit shail be - . � deemed revoked � „ TEL. STATISTICAL CLASSIFiCAT N APT. CONDO. � coNTencroa fAhmanson llev. rvo714837127 � LICENSED CONTftACTOR$OECLARATION . � LIC nA55 NO. '�`� DWEIL UNITS I hereby affirm fhat 1 am licensed under provisions of Chapter 9 ADDRE55 NO. SEWER MAP (commencing with Section 7000)ot Division 3 af the Business and LIC. Ig Professions Code,and my license is in,Full force and effect. CITY El Toro CLA55 &-�- BK � . -�� VALIDATION $ � �' ' - SQ.fT. NO.OF . NO.OF CHECK � ^ license Num6er 4b5688GBC�;�.cioss B-1 SIZE STORIES FAMILIES j{ ONE a , VALUATIO!! �i ; �;t Q� gAhmanson Dev. oesceiarioN oF woeK %���X�.������ "Ew X❑ �,��—f7� p Contractor pote ADD ; '` � }i s � ° s G� � 4 ❑I am exempt under Sec. CP.RPORTS S � �ALTER � I.� �f i.L}� B.&P.C.for ihis reason .REPAIR ❑ s 4 USE OF � � J�;� cs . Dp�e: EXISTING BLDG. ��'�� $ignature APPLICANT 1EL. i S.McGinnis 7148612311 FiNat �7 , �—�,� OWNER-BUILDER DECLARATION PkINT1 NO. DATE�"� � _bhereby-affirm that-I.drn exempt from-the Contractor's License 1��j � taw for�he following reason jSection 703L5, Business and ADDRESS Z29�� GOl$271 S Yln s Diamond Ba RNAL � � � '_' ' � " - � n ProfassionsCode): 6UIDNTG ��� � �� ' BY ��J(u�� ��9..�� '� . . ..�. � . . � � .� I, as owner of the property, or my employees wiih �ADDRESS . .- b�-' � ages as their sole compensation,wil I do the work and . - � `�� � �ihe sirocture is no1 intended or offered for sale(Secfion �OCALITY - �. 9 � � D'�9- � TEL - �''� � . VING 7044,Business-and Professions Code). Mo , � OI,as owne�of the property,am exdusively tontrdding CONTRACTOR NO. � - �� - with licensed contractars�to consiruct ihe project(Seo , �" -��b.F.-�I'�5 ' ADDRESS tion 7044,Business and Professions Code). � � z`'. . REQUIRED TOTALSETBACKF I . ` _. ..°. '�.l:..�-�a., ' . ��- " � � CONSTRUCTION LENDING AGENCY � SET BACK YARD HWY PROR LINE WIDTH ' - � 1 hereby affirm that ihere is a mnsiruction lending agency for FRONi - � � L� f �J`��O tJ ' ��ihe performance of ihe work for which ihispermit is iswed RL - � � - -�� '-�-�-- ""` (Sec 3097,Civ,C.). SIDE �� �� - m T10T12 .. . P.L . , ..._.. ..� , Lender's Name ,./' r_/ � LDMA Ref.# - . P.C.Fee$ �d'T Permii Fee i-� , - '� Lender's Address _I.ceriify iha1.J have read ihis application and stafe that fhe - Issuon<e Fee f3 ��� LDMA P/C# -�- - � Q a6ove information is mrreci.I ag�ee to comply with aIi CouMy Imes�igation Fee - � otdinances and Siate Idws relating�o building consiruction, iotal Fee ��� �� L�MA Perm.!i � . �--- ' and hereby authorize representat'es of this County to enter . � .upon� ove menhQned pro e y for inspediory.purp es. - . e}� �7 � SEE REVERSE FOR EXPLANATORV 4ANGU�+GE ^ � �--�Signarure of A}lim r gent - � Date, � - � "��� � o °. � � � 4 G� � O � (P N O- p 2 O Q �^ b 4 . � U N ; 'G1 A 'O � � j�. c�D�.� � � 4 Q n G � "0 F, Q �n naj 9 ? � N ,u TZ � 7� J� o � � �� O -O 4 "� �n 4 'D O � O -i� � � ff n '� �(D O� 'L W .�. cn ¢ n6 p- o °� � ?, p . � � Y � O ^ � O F � �� J a 7� � O S (9 ' ¢�' L . 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