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HomeMy WebLinkAbout1552A 1553A �, _ _ _ � VJORKERS'COMPENSATION'DECLARATION . � . � . . . � - �ro6y af`��� �`�� =;ave a ce"�?�ccb o=consent io sei'r ����.����1�N� ��R--:�l,l11DI��:N����� PERMIT - 7� � nsure,or a certrficafe of Workers'Compensafion Insuronce, . � or a cert�fied copy thereo4(Sec 3800,�ab.c.) COUNTY OF LOS ANGELES BUILDING AND SAFETY , Policy;No. 7N'�G—Rl7S�ompany. �g�T T«,��3t BUILDING iJ /'� !`� � Certified capy is hereby furnished. FOR APPLICANT TO PILL IN �.���(�C' j � l�r�� � nooREss ��..�-,c_ �.. n� ��Caruf�ed copy s f�led wirk rhe counry bu Iding inspec- BUILDING ��g� ZZggS Hilton Head Blda. 26 � ( 2 4� fion deparimeM. ADDRE55 ,7�.-JJ , oote aPpu�aoi S.McGi.nnis cirv Diamond Bar ZiP 91765 �ocnuTr - CERT�fICATE Of EXEMPTIOMFROM WORKERS'� � ND.OF BLOGS �: NEAREST ..: _ . .,. -- - - COMAENSA710N INSURANCE ' . . SIZE OF LO7 NOW ON LOT � �� CRO55 ST. �This settion�need not:�.be complefed if ihe permit is for one ASSESSOR � hundred-dallars($700)or less.J . . , �. TRACT /{ BtOCK LO7 NO. /�qp gppK PAGE PARCEL . � .. .. . TE E ZONE MAP � ` � '`� .� . . I�ceriify-_thof in the,performance of the work tor which this �`+'/NER Al1ID$riSOri D2V: N��81881�F7 NO. �` ��'^P ��:�. permit is issued,I shail nof employ dny persoo in any manner SPECIAL � A. so:as to become subjeCt to ihe Workers'Compensation Laws. � �+DDRE55 ].QQI COIItt[t2TC2 DP. CON�I710N5 �Q ` ' uTv Irwindale Z�P 9ll06 � Date Applimni � _ � NOTICE TO APPLICANTi"Jf,�after making ihis��Certificate of ARCHITECT OR TEL. ' DISTRICT G20UP NPE FlRE PROCESSEO BY .,[� Ezemption, you should become subject fo-�ihe��Workers" ENGWfER 736;F, F. NO 2 CONSL ZONE Com ensation- rovisions�.of the labor Code, ou m�st forth- ls"�' "W P P Y ADDRESS 825 Colorado Blvd. LA 90041 �� ' ��. �a with comply th.such�provisions o��this permit shafl be TEL. . STATISTICAL CLASSIF.�carioN aPi. CO DO. :��Z - deemed;�evoked, : . ��..-. , :��G�,- CONTRaQOR hM1ri O NO. � LICENSED CONTRACTORS DEClARA710N � �= CLa55 NO. ''�'"'� DVJELL.UNITS uc. 1 hereby affirm thot I am Iicensecl_under provisions of Chapter 9 AD�RE55 l3 1 El Toro rvo. 465688GB� (commencing with$etlion 7000)of-Divisioh 3 of ihe Business and ��� � SEWER MAP . Professions Code,and my license is in full farce and effect CiiY �l TOYO CtA55 B-1 ��aK � . , VAL{DATION - � 4656g$G�C �.� $ 1 SQ.fT. NO.OF NO.OF CHECK ;. ' � . LicenSe.Num6er Lic Class SIZE fjQ� STORIES FAMILIES t} ONE �. � . -. . � .. - . .s- .. yq�yTyyqyy�y � ... VAIUATION - __.. ':. ConiraCtor/\�"t�Tfi571'I�S()fl nPV. Dpte �� �� � DESCRIPTION OF WORK T�M1'1"Tn1Lz'i.454"ri'A'ELS ADD ❑ S e�"7 �r�1 J.C�r � 4 ❑I am exempt under Sec � CARPORTS ALTER � , � �` �' � '�^�i s 8.8P.C.for ihis reoson � S REPAIR � �� i�,�v Date: USE OF �EMOL �� � i _ EXISTING BLDG. � . _ �$ignature . . .APPUCANT TfL fINAt - � t� ?���;� : f PRiNT>S.iIcGinnis No7148612311 �, � OWNER-BUILDER DECLARATION DATE �j�'��- . � y.G � 4 hereby-affirm.�hat I am enempt from the Contractor's License 229QQ G01C12II $�7YltlgS D13IDOriC1 $d �' ' � � law for ihe following reason(Seclion 7037.5,Business and ADDRESS FINAL " - � Professions Code):. . . .... .. ..- . �. PRES N7 .. . . . .-gY . -.h'"}{i.,�,�.' ' - ... _. . ...;, , , �, BUILDING � � � I, as owner of�ihe properfy, or my employees wiih AODRESS - , � �;,j_('a ages as iheir sole compensation;will do the work and �pCAtiTv , . �he sfructure is no�inlended or offered for sole(Section � � �i`�'� ' 7044,�Business and Professions Code).�� � �� MOVWG TEL + �� '� - � -� - � . n I,as owner of the properiy,am exdusively cOniracting CONTRACTOR NO. ; ! ��.� %,5 ! `"'���wiih licensed contractors to consirucYthe project(Seo -���� ' ADDRESS tion 7044,Business and Professions CodeJ. ' o e o( 7,`7=,�,r � - CONSTRUCTION LENDING AGENCY � Re4uiaeo yqRo Nwv TOTAL SETBAIX FROM xisr. . � . SETBACK PROP.LINE WIDTH I hereby affirm that fhere is a construction lendin9 agenry for FRONi . v��i���-'°"'��`S'� ihe performance of�the work for which-this permit is issued P.L � � - . (Sec.3097,Civ.C.). SIOE � '� ' none P.�. __ _ Lender's Name � �pMA ReE M m Lendei 5 Address� P.C.Fee$ -��a Perm��Fee *��•� , - '-: j i _I certifiy that I have read ihis applimtion and stafe that the Issoance Fee ��'`i� IDMA P/C# � �Q above information is correcL I agree io comply with all County Invesiigorion Fee �]/ ' - ordinances and State laws relatinq lo building construdion, 7ota1 Fee ��° /'� LOMA Perm.# � � — and here6 authorize representativas o is County to eMer . .. � • � upon f ove-men io ed property f i pec�ion pos . - � �� a � d SEE REVERSE FOR EXPLANATORY LANGUAGE � � ��� o . . , e��'°^�"� . Signot�re of Applimnt or Agenf ' � te�-_, - -- - -��� 2 0 o •• -*� _ � v � o �0 n `� '^�cn � d O S �Ci Q ' j^ ("D� �O.- � O -�p �-" 9 �'N � . 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