HomeMy WebLinkAbout1492A 1493AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
11nsure, ora certificete of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lab, C.)
Policy No. 7634-911&mpany
7 Certified copy is hereby furnished.
O$ Certified copy is filed with the county building mspec-
l.� tion department.
S.McCinnis
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ($100) or lo-)
'I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
'Date Appicant
.NOICE TO APPLICANT: If, after making this Certificate of
-Exemption, you should become subject to the Workers'
.Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit- shall be
.deemed revoked.
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that 1 am licensed under provisions of Chapter -9
(commenting with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 465688GBC Lia ClassBB=1
Contractor Ahron—nn D—i Dale
c m exempt from the licensingrequirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No. _— Date
OWNER -BUILDER DECLARATION
I hereby affirm that i am exempt from the Contractor's License
Law for the following reason (,Section 7031.5, Business and
Professions Code):
I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure isnot intended or offered for sole (Section
7044, Business and Professions Code).
I,os owner of the property, am exclusively contracting
with licensed contractors to construct the project (Seo
tion 7044, Business and Professions Code),
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction [ending agency for
the performance of the work far which this permit is issued
(Sec. 3097, Civ, C.).
Lender's Name nnna
Lender's Address
I certify that I have read this application and state that Iha
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon in ,ave-ment ed pr p ty for inspection,purp es.
�C
Sigi,nfure of .Spp -cant do fent Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
APPLICANTPR! S.MCGINNIS
,'jl48612311
ADDRESS 22900 Golden Sp r.in s Dr.Diamond
PRrSENT
FOR APPLICANT TO FILL IN
AoDRESS %
' '
•
BUILDING
A, 'I22891 Hilton Head
LOCALITY
MOVING
TEL.
NEAREST
NO,
ADDRESS
CITY Diamond Bar ZIF 91765
CROSS ST.
TOTAL SETBACK FROM EXIST.
SET BACK YARD HWY
TT�� NO. OF 81 DGS.
SIZE OFYOT NOW ON LOT 0
ASSESSOR
MAP BOOK
PAGE
PARCEL
USE ZONE
';:i ,• J
TRACT 36346 BLOCK LOT NO. 6
K-3 3�y
NO
T
TEL.
Inyestlga,lan Fee
SPECIAL
OWNER N
�e'0
CONDITIONS
DISTRICT GROUP TYPE
FIRE
PROCESSED BY
ADDRESS
CONST.
/C) III
Z000DIE-
Irwindale ZIP 91706
CITY
ARCHITECT OR , TEL
STATISTICAL CLASSIFIC:AIION
APT. CONDO,
ENGINEER B&E Eng, NG2132545134
CLASS NO. DWELL UNITS
ADDRESS 825,Colorado o B vd LA 90
SEWER MAP
CONTRACTOR Ahmanson Dev148371279
RK PG,
VALIDATION
LIC. 5
ADDRESS 23861 El Toro Rd. NO
vawnnoN
CITY El Toro c ASS B-1
$ 294 630
g' �- P'
SQ- Ft NO, OF INC), OF CHECK
SIZE 2 STORIES 2 FAMILIES8 ONE
$
m4ex21
DESCRIPTION OF WORK condo NFW
ADD
-
_..
I ®. 66492
,L d tr
!,
AITFR
FINAL ) r
e of(, Z
b d Gc
- -
REPAIR �
DATE
US DEMOL
FINAL /�
�� 7. 1 O "' 8 5
EXISTING BLDG.
ev
APPLICANTPR! S.MCGINNIS
,'jl48612311
ADDRESS 22900 Golden Sp r.in s Dr.Diamond
PRrSENT
BUILDING
ADDRESS
LOCALITY
MOVING
TEL.
CONTRACTOR
NO,
ADDRESS
REQUIRED
TOTAL SETBACK FROM EXIST.
SET BACK YARD HWY
PROP. LINE WIDTH
FRON t
P L,
SIDE
P.L.
P.C. Fee $ ✓ 2—
S-1
Permit .Fee /i/l 7—S-1
�' S�
Issuance ren ✓
Inyestlga,lan Fee
Total Fee /j,,
Yee)$ X99.14 ase
SEE REVERSE FOR EXPLANATORY LANGUAGE
z149,3A
f{ s o s s a 1
C8i0)-
s1,12i,i;06
i 9-65
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