HomeMy WebLinkAbout1536A 1537A (8) � . _ - _ _
.. WORKERS COMPENSATION DECLARATION `� � �� � ' � �
S 1 hereby affirm ihot I hove a�ceriificate of wnsent to self � l
� insure,oracertificaleofWorkers'Compensafion��s��a��e, �APPLICATION� FOR� -BUIL�DI�-NG- PERMIT ���
� or a certified eopy�hereof�(Sec.3800,Lab..C:) � � .... . . '-
Poi;�YNo: 7634=811�omPa�y Pac. Tndemnity
COUNTY OF LOS ANGELES BUILDING AND SAFETY
� � .Certified co is here6 fumished. � . , ADDRE55 ����f+.l r'r-� i�s-C� '
❑� PY 1' ' � FOR-APPLICANT TO FILL IN ' ��
� Certified mpy is fifed with the couNy 6uiiding Snspeo BUILDING � t]_� - .
� tion departmenC ADDRESS ��85 22585 Hilton Head Bldg. 26 ��
� oma nppu�anr S.McGinniG cirv Diamond Bar zia 91765 iocaurv
�`" NO.OF eL�GS. NEAREST- ������ � � �- � '
I '� - �CfRTIFiCATE OF EXEMPTION FRONi WORKER$`�� - �---- -�--. _-�-�-� �- --•��-��� ---�� -�� ���--�� ����
; ' � � ��°�COMPENSATION INSURANCE . SIZE OF LO7 NOW ON LO7 O �� CROSS SL � �
E (Thi4 rection-rteed nof 6e complefed iF ihe permit i5 for one ASSESSOR �
i hundred dollqr5($700)ar less.) , TRAC7 363�+6 BLOCK LOT NO. MAP BOOK PAGE PAR�EL
� � ' � OWNER N�� USE ZONE ....�P. ... .._. ... _�/' .� .
i certify ihai in ihe performance of the work for which this �� !'Y"�� �� 'Y
� permit is issved,i-shpll,not employ any person n any manner - - SPEqAL �d
� so asio become'subject to flie'Workers"Compensotion Laws. ADDRE55 �-��I. COIRtReI'CC' Z1Y. �- CONDITIONS ;.,o
=- Irwindale 91706
jDate.,".._ '" ...' APPYimnf --" .' :� ARGHITECTOR ZIP TEL. ` . .. . �
NOTICE TO APPLICAP3T-�"!f;-�cfter mokin fh�s Certificate o4 � DISTRICT GROUP lYPE . fIRE PROGESSEDBY ,�'o
i 9 eNcweea $&E En . rvo213254�134` eoNsr. zoNe !v
� Exempiion, you should become subjetl to the Workers'
Compensofion provisions ot-ihe Lobor Code,you must forth qpDRE55$Z.Jr LOZOT�3.C�0 $IVa.. I,.� 9�QI}1 !u . ^°� �-a'
�{ with comply witFi:�such ptovisions or this permit shall be y
, deemed re�oked. = Ahmanson Dev. Tt� 714837127 STATISTICAL CLASSIFICATION APT. NDO. ' �
_ .„ . .�.... .. . CONTRACTOR NO. .__._._. _ -- :� ._.. :__ :..: _ ... ,.:
i LICENSED CONTRACTORS DECLARATION ��� CLA55 NO. �'�- DWEIL UNITS
I I hereby affirm tha�.i am licensed under provisions of Chapter 9 qooaE55 23861 El Tor.o No.465688GBC �,�.,
i (commencing with Section�7000)of Division 3 of the Business and - ��� SEWER nnnP -
� Professions Code,and my license is in f�li force and effect ` CITV CLASS $-1 � - eK- -� - -� -��-- - VALIDATION
I � - � SQ.FT. NO.OP NO.OF CHECK :
' �icenseNumber 465b88CBC �;�:classB-1' ' sizE 800"sroRies FnnniuEs 4 oNe ' �� '_�
I vawanoN
� � �.� DESCRIPTION Of WORK ��''�'�Y������5 NEW � - �� � �
i co��ra��or Ahmanson Dev. pare : s K�,e,q ;
CARPORTS aoo � -
�I am exempi under Seu ' - � ��
i _ , ..` : - ALTER ❑ �, �� � 'l...� �'.
REPAIR -"" �� � �� -" �
�, 8.8P.C.for this reason � �a S � - ---
I Date: usE OF ❑ 1 a- ��4-�/ �
i .. EXISTWG BLDG. DEMOL ��
' � APPLICANT T:L � q� �}i,.C S-�:
�� Signarore � pR�ti7� S.P1cGi.nnis No7148612311 pATEL ,S(D � � �� .
�� OWNER-BUILDER DECLARATION �., . . . �7 .� ��v ..
<I hereby-affirm ihat I am exempt from ihe Controctor's License _ , �
�law for the fallowing��reason{Secr�or,7031.5,Bus�ness and � ADORESS 22900 Golden 5 Tlri S DldmOnd Y FINAL � /yy� " ' �� . '`"�- -
Professlons Code)�.. .. . ......._. PRESENT__._. .. . . . ... . .. .. . . By r�,'���"r �zr�--�� -: -_...._._.�.��-. .-_ . .�
❑ BUILDING --
I, as owner of the properiy, or my employees wifh ADDRESS
wages as iheir wie compensation,wiil do the work and . � ���
the slructore is not inlended or offered for sale(Section �OCALITY , � ' J.�..7�`
7044;Businessand Professions Code). - - - 4noviNG 7EL -
� �,as owner of ihe property,am exdusively contracting CONTRACTOR NO. ' ' . � �a n � i a"� .
���- with licensed eoniroctors to construd the project(Seo- � . - � �� y � N���
ADDRESS , m w O'�,�r rj
tion 7044,Business and Professions Code�. � � � .
RE�UIRED TOTAL SETBACK FkOM
- � -CONSTRUQION LENDING�AGENCY ' �gq�K vrRD Hwr pROP.uNE WioiH e u o C,;-J j�,"
� I hereby affirm thai there is a constr�clion lending agency for PRONT - � .
-ihe performance-af ihe work for which-this permit is issued p.L - � � - - -�-7 � g,_,&i` -�-
(Sec.3097,Civ.C.). SIDE , -
�
P.L.
� Lander's Name riORC.' ..... . . .... . .....::..-��....
p LDMA Ref.N
P.C.Fee$ ✓L3+ PermiiFee �/"�S ,� �-
- Lender's Address .
I cerfify that I have read ihis appiication and state ihat ihe Issuance Fee �a `'S� IDMA P/C# -
M a6ove informaiion is correci.I agree to comply with aIl Counfy Invastigation Fee /' ] ^�[ -
ordinonces and State laws reloting to 6uilding consiruction, Total Pee (y d' /Y LDMA Verm.# - - --
and hereby authorize representatives of this Coumy to en r
m upon fh , ove-me�n�per/y��-�'�,,r inspection�rp, eg. � f;s,� ,�
.Fy}(i/�v„�v--- � SEE REVERSE FOR E%PLANATORY LANGUAGE
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