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HomeMy WebLinkAbout1542A 1543A � WORKERS'COMPENSATION�DECLARAiION �- � � - . . � ' ^`�, p . `nsure,y�ora'cerfifca�feof�Workerzr9Compe�safon Insurancef /1��`I��■ t�� ���- ��VV'��D��V� ■ ��.`�' • . C� � or a ce[t f ed copy thereof(Sec 380D,18b:C) COUNTY OF LOS ANGELES BUILDING AND SAFETY � Ocy,IJo �7(-�7(��-R7Y�ompany� Par�.� Tnlo„�„ir.. BUILOIN6 »�nj�,/S p. . Cert t ed copy is here6y.fu nished._ FOR APPLICANT TO FIIL W ADORESS oe :�e� e•' � �Certified copy is filed wiih the county building inspec- gUiloiNG =rio„depa.rmem - - - nooeess 22885 Hilton,Head Bld . 2b -�,� • ` 'S.McGinnis Diamond Sar 91765 Date.-� . .... Applicanf CITY ZIP LOCAI.ITY CERTIFlCATE OF EXEMPTION FROM WORKERS' � � NO.OF BLDGS. . NEAREST . . - . .. . . '��--����� ----- COMPENSATION INSURANCE � � 5¢E oF toi NOW oN�07 CROSS ST. � � � - (This�setlion need-.noP be'�.completed if�the permit�is for one ASSESSOR hondred dollars($10p)or less.) . . TRACT 36346 gLpCK LOT NO. MAP BOOK - PAGE PARCEL � TE�' USE ZONE ��P � � � OWNER .�r1IDd.riSOR NO. I.cerfify fhat i jhe performance ot ihe�work for whic8�this NO. � ;} permit is issued,I shall not employ any person in any;manner ]_�01 COI➢IILET'C2 DY. � SPECIAL '� so-as fo bemme sub�ed,f¢.Ihe Workers'Compensafion laws. ADDRF55 � CONDITIONS �'� oore nPPG�a„r aTr Irwindale ziP 9170b oe NOTICE TO APPLICAN7�Jf, affe��'making ihis'�Certificafe of ARCHITECT OR � TE � DISTRICT GROUP NPE FIRE PROCESSED BY I� . Exemption,�ydu�should,become subject fo-1he Workers" - ENGWeER .�S&� EII . N�13 2 5 4 5 134� CONSL ZONE � Compensation�provisions�so£dhe labor�Code,you�must forih- qDDRE55 $Z5 Colorado Blvd. LA 40041 �� y�> `�d � wiih�comply with�.�such��.provisions or�ihis permit shail 6e . �'�y deemed,revoked. . � ;. .. ,, Ahmanson Dev. Tf�148371279 STATISTICAL C1A551FICATION APT. C rvoo. '..2 CONTRACTOR N LICENSED CONTRACTORS DECLARAiION �_��_ CLA55 NO. �-� DWELL.UNI75 1 hereby affirm ihot I pm I�censed under provisions of Ghapter 9 ADDRESS 23861 EZ TOT.'O No. 465688cBc (commencing wiih Sectiod7000)of Divisiort 3 of the 8usiness and ��� SEWER MP.P Professions,Code„and my license is.in.full force and effecr. CiTv EZ TOTO CLASS B-1 BK � -VAUDATION � - SQ.FT. NO.OF NO.OF CHECK LicenSeNumber 465688GBC �;�.��.aass B-1- ���� SIZE 8�0 $TORIES FAMILIES�1 ONE - ._... ,: .„�, ..,. �... , . . . ,. . VALUATION � Co`nTracro. /thman Snn nav. oare ` � -��"-� flEsc7t�Pi�oN oF�woRK����X�'�' � A D O �S � f,��' � 1 � � c'{' b ❑I am exempt unde�Sec. __ CARPORT$ ❑ , h:� s � �,L,� ALiER 4 8.8P.C.for ihis reason REPAIR ❑ s � �a a�^,`j� Date: USE OP DEMOL � � EXISTING BIDG. ❑ .�. � R�� ..' � $ignature . �.... - APPLICANT . . . TEL FINAI -�'! : � . . OWNER-BUILDER DECLARATION PRINTj $.�CG1RI11S Naz4ssi2sii DATE `�'���G . _ �....� y � -{j:�y '�� -..I=herebyaffirmthat-I.amexempHromiheContraUar'sLicense �— ��� � '�. Law for ihe following reason(Section 7031.5, Business ond ADDRESS 2` " ' F�NqL �� ' _ � ' '- - ProfessionsCode): . . . . ..' . . ._.: PRESENT � � � - By iRf.-L-r`"'"� . �. - ,._ BWL�ING �� ��� �y�� � � I, as owner of fhe properfy, or my employees with ADORESS ! . -:: �. ` � wages as iheir-sole compensation,will do the work and , � � � -- � � � ihe siructure is not intended or offered for sale(Sedion LOCALITY � 7044,Business-ond Professions Code). � MOVING � TEL � �� ' ' ! `��'`-�f-P . � I,as owner of the property,am exclusively contra<ting CONTRACTOR NO. _ �� 8 Q tl o � �wifh licensed coniractors to constroct the projecY(Sec- � - ' - �� - - -- ��-I -�' - tion 7044,8usiness and Professions Code. AD�RE55 .. - ' RE�UIRED TOTP.I SETBACK FROM . 1 s m� I,I S CONSTRUCTIONLENDWGAGENCY - SETBACK YARD HWY PROP.LWE WIDTH � - -� �- I hereby affirm ihoi fhere is o construction lending aqency for fROM z m s���{-��iJ��' ��ihe�performance of�the work foi which this�permit�is issued -p.�. � � �� � - � �� (sec 3ov�,c�.c.}. sioe 0 7 i 4—�'� P.L Lender's Name riOri2 � � - �S 1 a�' �o,�,Ref.� m Lender's Address � � - P:C.fee$ -�[/. Permit Fee -- ' -- � .Lcertify ihai I have read this application and state that the . issuance Fee /��'S� �DMA P/C� � . � above information is mrrect.I agree fo mmply with ali County Investigofion Fee / 7 �' ' ��' ordinances and Stafe laws reloting to building consiruction, _ � Total Fee �9�' /S L�MA Perm.# � --� � � and hereb uthorize representa�ives fhis County�o enter . .. m opon a ve-meniioned propey y or nspection p_µrposes _ . . a �� .,,�c,.%—�%'—� . SEE REVERSE POR EXPLANATORY LANGUAGE � Signafure af AyplicaN�or Agen� -. . Dat .-- . . . 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