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WORKERS'COMPENSA110N DECLARATION .
g �nsure�ora�cerlfcatleofWorkesr'Comrpensationensvrance�r �PPLIC�►►`�10-N� FOR _BUILDI,tV�G:�. PERMIT � ����
3 or a cerrified mpy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY '
� 7634=$IJ� Pac. Indemnit
� Policy:No. mpo^Y . Y BUILDING q /)� /, ,� ..
g � Cer�i4ied mpy is he�eby fvrn�shed. FOR APPLICANT TO RlL IN ADDRESS .2���.� ��� /�-�-�
9 Cerfified copy s liled with the:munty bu lding insper � BUiLDING
� � �iion-depor�ment. ADDRE55 22885 Hilton Head Bldg. 26 �� ,�-��
t S.McGinnis arv Diamond Bar ZiP 91765 iocnuTv
Date APPlicanl -
- - CfRTlHCATE OF EXEMPTION fROM WORKERS� � NO.OF BIDGS � ', NEAREST . . . _. . . . ..
- � �� COMPENSATION WSURANCE - - � � � size OF�OT NOw Orv i0T '� CRoss 57.
(This�section need�not be completed if�ibe permit is for one 36346 ASSESSOR ,
hundred.dollars($700)or less..). . . TRA�T 6LOCK LOT NO. MAP BOOK PAGE PARCEL
Ahmanson Dev. ni�4 188147152 usezoNe �+P " �/j� s
� I certify.that in the performance of Ihe�work�for whith.�his OWNER Cf' NO. � T��.2� � ,�
permit is issued,I shall not employ any person`in any manner SPECIAL `,,o
so.as Yo become subject�fo ihe Worke�s"Comp'ensaYion Laws. ADDRE55 l��]_ CONDITIONS ,V
� aTv Irwindale ziP 91706 Q
� Date APP���a�f ARCHITECT OR TE� / DISTRICT GROUP TYPE FIRE PROCESSEO BY ,.,�.
NOTICE�TO APPLICANT',it,�aher�making this`Cerifficale of ENGINEER B�r� F''ng. NO�3-3254513"� CONST.� ZONE �_W
Exempfion, you should become subjec� to the Workers' / �
Compensotion prov�sonrof ihe lobo�Coda,you must forth qDDRESS 8Z5 COI.pT.1Cl0 I3lvd. LA 40041 I a � ��V1
� with comply i!h such provisions or this-permit shall be TEL STATISTICA�CL4551PICATION . APT. C NDO 'Z
deemedrevokeCl. CONTRACTOR Ahmanson Dev. No.714837127 -
LICENSED CONTRACTORS DECtARAT7pN ���, CtA55 NO.°�'�_DW[tl.UNITS
I hereby.afPirm that I om licensed under pravisions of Chapter 9 AODRE55 'j NO. SEWER MAP -
(commencing wifh Sectiott7000]of Division 3 of the Business and , LIC.
Professions.Code,and my license is in full force and effect. CITY E'1 LbTO C1A55 B-1 gK � �VALiDAT10N
� � �� SQ."rT. NO.OF NO.OF CHECK :_
License Number 4656$8GBC �[;c.class�-] � size 800 sroeies FaM�ues 4 oNe . �-
. , VAWATION
Comrac�or Ahmanson Dev. pate oEsckianoN oF woRK 3>�fi��X$�Y�Xd�$�#£&� NEW � s �5' ��� �5:a h
ADD ;� �. .. ';
I ❑I am exempf under Sec. CARPORTS ALTER � � *. E �E�-�� _.
- B.&P.C.for Ihis reason REPAiR ❑ � S � ( a ::,�,G�� �
. pa�e: USE OF DEMOt
. EXISTING BLDG. � �c ,f�L ��
� $ignafure�,�: . APPLICANT TEL FINAL�,
- OWNER-BUILDER DECLARATION IPRINrI N� DATE �,�'w �- � _--�� � � G�„�� ��
I�herebyaffirmthatl.amexempifromiheContraclor'slicense 22900 Golden $ T�II S n1dI110IIC�{ �3. PINAL � ��� �
Low for the following reason.(Section 7031.5,8�siness artd �q��PE55
BY I1� �_;_.,
Professions Codej: � , ' �� - � , PREsetvi -
. ❑ BUILOING :,
I, as owner of the properry, or my empVoyees wnh � AouRc55
�wa es as their sole com ensation,will do the work and , � L
Ihes Iructore is-not intended or offered for sale(Section - �n�A�iTY . ,��.9�t
� 7044,Business and Professions Code. nnOVwG TE��
❑ � CONTRACTOR NO. . . . ._.. . . � .rp�,.,a o o a '�
I,ds owner of ihe property,am exd�sively conlmciing
� with licensed cantradors to construcl fhe proiecf(Seo- ��
� tion 7044,Business and P/ofessions Code). ADDRESS � b�,r
� REQUIRED YARD HWY TO1AL SEiBACK FROM I � �
� � CONSTRUC7ION�LENDINGAGENCY SETBACK PROP.LINE WIDTH - • s x,�:'�,%��
I herehy affirm Ihat there is a construction lending agency for FRONT - �.
� the performance of Ihe work�for which�his permit is issued � P.L � � [i" i �—�7 �
� (Sec 3097,Civ.C.). 51DE t . � '
'r P.L . , . .. _ ., ......'
m Lender's Name �j �[' � LDMA Ref.H '
� P.0 Fee$ ��r 7 Perm'i Fee �,J�• � � ,
- Lender's Address � �
J certif y ihat i have.read this application and stofe that�he Issuance Fee �� � �- ��+F��� " � - .
�Q above informaiian is correct.I agree to mmply wit h a l l Counfy imastiga�ion Fee / ( � �-
� ordinances and State laws relating to boilding mnsirutlion, Total Fee $� '��'J LDMA Perm.k � � ��-""��"
and hereby authorize represeniafives of�his County to enter � �
� upon th bnve-m�ti ned property for inspection purpos c. . ..._ .
a p� SEE REVERSE FOR EXPLANATORY LANGUAGE
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