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HomeMy WebLinkAbout1558A 1559A i 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 =vrv- . � Y�pr � Signoture of pp ant o�Age�f ate / � .� � � ' ! 0 0. � T � Q ,a � Q � n m N �¢ o a o s r � O �C �N � � fl � � 4 fl . � � � •O -f, �p .� Q �� Q Q 3 n �O `n °c c�q `° � N o .o � 3 m � r � Q 6 � Q y � a.a O o j N 'q � rr,-n (l Z ° 3 � � a �c� v � o �_ � N . q � 3 O O � � . 1 0 7 O t�. 1�/�. c�Q �� �j � � �7 O ;� � T ro� N N � o � � 0 N Z � .. 3 St�� :D �O 9 QN N Q "�O T o 6 0 0 � t p ,� , � � � m � w � y � n a , c d A Z % O io a o. � � ° 4. �' m o � (- � r`r" --" �Q 9 . � �. y� � � % 9 � O �y 9 n < 'r"'-�- i,r � � W i• � b 'CL�.-^� � �; °'m 6 f_ + ' v: � � � � � p `,�, �° z v m � • O � , � O � N I ' .. � , -O�.� � n' ' � �� 3-S'R m h N S � . , ' ' � � �.��p � � � � . 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