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, � - � "���
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