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 � .
F Q � Q fl O � � � �
T N O 3 �' J (�� N � � � 'O
(P O N t' c4 � ��, O.-O ?, �p N P'
r- � a a a o o' a m o� �o � � ,�„
; � c� 3 o F� �o � '��: �
� m„ o o s s � �o � o �o
=n � 1 � � { � < c � o o O
.. � ; 2 W % �-� m N �^ a CG A 'O
� G � -
. 3 4°G ' � t' Q` � L1- � fiN , � C1
O �6 � 1 � `� . a G O W Z
m d
�
= a� ;� 3 -'
� o 0
�� W
o�
� �. o� P
r�. �, . 4
"i" �,� � ' q A O
,a�' 'C..� ..
G ;�' � o� c.
°7'�' a
! � W
.�..� `� a a�o.
� N
�a
s
n
c
m
, Z
N
'O
T
_ �
�
�
N
"x'
�
�
r �
. ,��5,3•�.��. } �
p„�.n� °' A r.�
. . , , '�� o -�, �^ e ^� � y � 6
tpsf �'� � `�,� ���.� ti �1 C
�tr a-� p - N�°n. �A.,.� ¢� o� �;� p � � � �<
. , . J .,. Lr'� Q � ^ ��� sa.N c Q --���X 5.���g, K�.`�, .iy � C
. . n� ��n� �"c c' � � �a o `� Q � N ° s �� r.`"N �o� �c�, � � C
O o ,3 • " n� ;, �`"'s �0 c � � m � o o».-.,»��`° �.� ^ ��,s° C
. . _ Q p X.� A�' ..p�.�-^ `Q C,,n �� y `�" ?'A'�; ^ �L -�i o �':� Q b F � C a � � '
. � �� cv o � ?, � ���.,�, =Q �� � 10 Np -c m p �o °m ,�a� � � K�� y '.�s•m � y o o C
o � �' �m o 0 o v s� � ,v�. . co o �� 'Y�o � ���r � 3 �
� �-��vta.`'. � a p �""-a.� � �� ^.�o s Q�2��p�� o� a� X t
r o A � o=m �;`�c °� � °,10 � � � m � �. e .-.,"r . `•'• � �D c
3 `~' p m c.^ °�"s a' �� p ��m m o ��-� -'s cso �` � �o � ^'�� -6 C
� � � � " � ,b� �� ��,. S -�S � � A O O ��' -6 m .+...m �".-cso Y`a m�L CD -"'v
� �. S p '� q (D , '!„t' ��•L+o �,.� ?..� 4.cD S.-� O'+ �n b ~.�t � � O .
n '6. , m .�
� m � o ��N.�� ¢�o¢'.acos�� oP-��`^¢ A� z � �"� * o ��
�"�,- c o -� �„� co 4 A v,� y A `'•xi ic o � �
fa � ;:.fi.�_ n o Q `� �m o„A,�o � o a L n'c'"�.".s� �•.�. �r.=° � � � �
3 ` ' �,�.,�o s.n � o m «..�c n tL� � y o �,
� t�0 £. ^ C N 3 �.^ m F�. N �t �' � P 4 `S q.�04`--• .Z CJ cL J Q
V' � o � `-':n v. P..� 'A p,••�� �^ N c?o� v. �..��.`^..��.��w o � 1 0
O t''a o "�5� ° �.t'-'o'� �"� �.m o� �° �o� s�� K'�s��n
+t � .Y`�w f (D K �� -! N S p �n ,�N Q P v�-i O �� av+ t� '
� " u � J . � �
� � ..� .,p� ���.{ o � � � s��'� Ao S`r�� � y _ , .
� _ � `� v ��.,-�i =� 2� m c c p.�, -�°- ,�..
�n �v n� �-..2�r^� � ..r^'�'".
O � '
. o c � �..Q n � � � �,..►�'"".
, S �s.° I....,.'�" .
N /....�r"'�.
✓...��i.
��«�"��..���
...�"`��.��i�.
. �.^"i�.�^'"'r+�.�✓^r^�^'�..
.�.^""'��,✓��
. �_�.�_l^'
_ ��.-
1�,,,.,...r"'.�"' �