HomeMy WebLinkAbout1550A 1551A (9) � WORKERS`COMPENSATIONbECLARATION p - . � � �
- i nereby�`firn 'hai i iave a cerfiticaie oi consent to seif p���'■ ��i�pN����f?l��-��U-I�C-:DI�NG �PERMIT � �
insure,or o cenif cate of Workers'Compensdtion Insurance, /'\ r
or a cerrified copy thereof(Seo 3800,lab.C.) COUNTY OF lOS ANGELES BUILDINCrAND SAFETY
Po�;�yNo" 7634"=817�mPa�Y PSC. Indemnity
Ce�tified copy.is he�eby fumished. POR APPLICANT TO FILL IN BUILDING .y. �i ��a
�� ❑ ADDRESS K..�-�'+1� /�^� �
� Certified copy-is filed with the coonty b�i�ding inspec- BUILDING ),
� r�o�depa.rme�f. nooaess l�$$ 22885 Hilton Head Bld . 26 �,
�ote� Applicam G _Mr(;ti�nni c CITY n' ZIP LOCALITV '
CERTIFICATE OF EXEMPTION FROM WORKERS' �� � NO.OP BLDGS. _. NEAREST_ . _ . . . . . . . .
� � - ��� COMPENSATION INSURANCE � - SiZE OF LOT NOW ON LOT O RO55 5T.
(ihis section need not be completed if-.ihe permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TE� USE ZONE - �P )J /
I certify ihat in the pe�formance of the work for which.ihis OWNER E�t1tIIdIlSOI1 DeV. N(�l$81,tF]�.52 Np_ /f��'����'7 ��
permit is issued,i shali not employ any person in any manner SPECIAI - �
so as to bemme subjeci to ihe Workers'-Compensation�Laws. ADDRESS ]_�QI�(]OliltReYCB DP. � CONDITIONS :V
: aTv Irwinda].e Z1N 91706 ;�
Date Applimnt � ;0
NOTICE�TO APPLiCANT:ilf;after`making ffhir-Certifimte of ARCHITEC7 OR - - TE�� DISTRICi GROUP NPE FIRE PROCg55fD BY
Exemption, you should becomB�subjeCt�to'fhe�WOrkerS' ENGINEER ��tE EIl . N02132rj1{. � CONST.- ZONE �W
� Compensafion provision9 of 3he labor Code,you must forlh- qD�Re55 $25 C07.pI'SCjO Blvd. LA 9D041 '�� ��y�'j
with comply with such-provisions or�this-permif sholl be TEL ' SiATISTICAt CLASSIF�CATION APT. CON00. :�
� deemed(evoked. . . � - � CONTRACTOR L:t1tIl3RSOIL ll@V. NO. . _.
-LILENSED CONTRACFORS�ECLARATION--. ���_ �CLASS NO. � '�"� DWELL UNI75
I hereby aHirm ihat I om licensed under prov.isions of Chapter 9 ADDRESS 23861 EZ `lOYO NO. 4 �Ei G gyyER MAP
(commencin with Section7000 of Drvision 3 oflhe�Business and
Professions Code,.ond my license:is.in.foll furce dnd effect. CITY �E1 TOTO CtaSS B-i gK � VALIDATION �
' � SO.YT. NO.OF NO.Of CHECK .
License Number 465688GBC �9a Ciass B-�- S�Ze $Op S1oR�E5 PAM�uES 4 oNe
� . .. .. . �� . . . . . VAWATION � .
Confractar ��RS011 DEV. pa�e � DESCRIPTION OF WORK ��'���X�'������ NEw ; ;f�'� �p-� � J`��
� CARPORTS �� ►
I am exempt under Sec. ' e
� AtTER � aTl` .."'d��
I B.&P.C.for ihis reason RE�AIR .❑ S .
� USE OF ' � `�'��
� � Date: ��:�� CEMOL �
I EXISTING BLDG. � -�
APPLI�ANT • TEL s a {J;{1� T '
-�Signature S.McGinnzs �714861231 FINAL �-�pf :
'I OWNER-BUILDERDECIARATION Pe�NT _ _ _ , _ NO. .DATE �eD-SC� �-- --j�']g t�:�,�Z J ;
� ,�I here6y affirm that I am exempY from.the Conhoctor's Li[ense , -
� Law for ihe following reason�(Secnon.7031.5, Business and ADDRE55 ll1&IIIOriCl Bd� FINAI� �. � -
Professions Codej: .". .. ' . .PRESE BY ���i/.;,`�-�'' -. . . '�.�- .".�
� eUIIDING � _ �
I, as owner of the property, or my amployees with ADDRESS ' �
wages as iheir sole compensation,wilbdo ihe work and ;� G r
the structure is not intended or offered for sa�e(Section � IOCALiN ' . � '� � J}t�f}
7044,Business and Professions Code). MOVING tEL.
� I,as owner of ihe property,am exdusively contracting CONTRACTOR NO. �:��' ° �' "-� �...�;;l
� with licensed contractors ta construct-ihe projea(Sec- - "�- "---�"-`
tion 7044,Business and Professions Code). ADORE55 . ( s ��J'�,-7 C?.
� CONSTRUCTION LENDING AGENCY � REQUIRED YARp. HWy. TOTAL SETBACK FROM _
SET BA�K PROP.LINE WIDTH � , �()��,�`'V
I hereby affirm that there is a consiruction lending agency for PRONT � '� � '-
��the performance of ihe work for which this permit is issued RL � , U �,1 �.o�1:�-rJ= "+
� (Sec.3097,Civ.C.). SIDE !
. . P.L . . . � � .,. .
Lender's Name 7ky t-) toMA Ret.R : - - ��
P.C.fee$ ���� PermirFee t-1�/�� � ,� ��-��
m lender's Address - � �
; �u, -� ;
� .I certify that I have read this applimtion and state_that the Iss�ance Fee � LDMA P/C A - - � -� � -
m a6ove informatian is correct.I agree lo comply with all Caunty Invesrigation Pee / --
ordinances and State laws�elating!o building consfruction, 7o+al Fee �/ <�-SJ LDMA Perm.# -�� -
u
and hereby authorize�epresentatives of ihis County to enter �
� upon 1 �ove-ment� ned prope i fo�inspetfion urpo 3. . �
a . '� �--�._. . . . ._.. .- .._t.;�.._ _.:
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