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HomeMy WebLinkAbout1520A 1521A (8) _ WORKERS'COMPENSATION DECLARATION . �� � ' ��� � APPLICATION FOR BU,ILDING PERMIT �, I hereby af£irm ihat I hove a cert f w1e of consent to self insure,or a certificate of Workers'Compensafon Insurance, _ . . or a certified<opy ihereof(Sec.3800,Lab.��C.) � � � � ��� �� �� � ��� � - � -�- � 7634-8'll8 Pac. Indemnity COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company � f� � Cert'rfied copy is hereby furnished. FOR�4PP11CANT T0 FILL(N qooeEss ���`f` ��. OW.-� � � Certi4ied<opy�is filed with the wunty building inspeo- gUI�DING � � ������� �"�� � �� tion department. ' ADDRE55 4r95 22979 Lakeway Dr. Bldg. 48 ,{�.� 5.McGinnis Diamond Bar 91765 Date Applicont OTv ZIP LOCAIITY CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.Of 6LDG5. � � NEAREST . . � . � � COMPENSATION INSURANCE � 5¢E OF I.OT NOW ON LOT — CROSS 57. (This section need not be compleled if�he permit is for one 3C�3[�(� � - n55ESSOR �� �� � �� h�ndred dollars(�100)or less.) TRACT BLOCK LOT NO. MAP BOOK' � PAGE PARCEL TEL ...... .. .........._ . .. ... . . USE-ZONE� � N.4P ' OWNER Ahmanson Dev. No.818814715 t/+1G- f I certify that in ihe performance of the�work for which ihis . � . S�CAL a permit is issued,I shall not employ any person ih any manner AD�RE55 1��1 Commerce DT, '���-'�� CONDITIONS O so as�to become subject ro the Workers'Compensation Laws. . . . V ' ��Ty Irwindale, Z1P 91706 Q, Dale� � ' Applicanf - �� � ARCHITECTOR TE�. � NOTICE TO APPLICANT: If, after making fhis Cerfificate of ENGINEER N� DI$TRICT GROUP. CONST. ZONE PROCESSED 8Y .,,_;V Exemption, �you ihould 6erome�subject to ihe Workers' W Compensation provisions of fhe Labor Code,you must forih- qDDRESS �v - N with mmply�with such provisions or this�permii shall be � � � - "7p[""""'-""'-"""` S7Ai1571CALCLA59FlCAT N APt. ONDO. � deemed revoked. . . CONTRACTOR Ahmanson Dev. No7148371279 �V — LICENSED CONTRACTORS DECLARAiION � �� �� ���. CL455 NO. DWELL UNI75 I hereby affirm ihat i am licensed under provisions of Chapter 9 AD�RESS 23861 �1 Toro� No 4�65688GBC (mmmencing with Section 7000)of Division 3 of ihe Business and $ Toro LIC. $— SEWER MAP � � � Professions Code,�and my license is in full force and effect. CITv CLA55 BK � VAIIDATION�� � �` ' ' ' �� ' � Sq.F�. 800 NO.OF NO.OF [F CHECK ' �icense Number 465688GBC �u�.ciass B-1. ��� size STORIES FAMIlIES oNe � � VALUATION �AI1ID3T1SOI1 D2V. DESCRIPTIONOF WORK Carports NEW � /)/� ConiraCtor Date ..,... ... ADD � S �" " .ti ❑I am exempt under Sec. �� � , � � �?'✓A� ALTER � S i;.� Gfo�� B.&P.C.for Ihis reason REPAIR � " Date: � USE OF DEMOL ❑ i '� 6�(�4 Y. EXISTING BL�G. APPIICANT.. . .TEL . . . ........ Signature- . . . . PRIN71 '�I .1 N . Z FINAL � / a _ �,:�; OWNER-BUILDERDECLARATION �ATE �yo--. � '" � I here6y affirm ihat I om exempt from the Controctor's License ZZ9OO GOZC12ri Springs Diamon.d B8 - . t. Low for the following reason(Sectio�7031.5, Business and ADDRE55 FINAL � � � G �, i-�!—"3� B �n C._.� ProfessionsCode): - . .. .. PRE ENT .. .."- -.....""...."......"".'."`-. Y ���L . .. � I, os owner of fhe ro ert . BUILDING p p y, or my employees with AODRE55 „ , ,,,. ,.. „„,_ _. . wages as their�sole compensation,-will do the wark and , . . �he structure is not imended or offered for sale(Section LOCnuTv � � �� � � � � 7044,Business and Professions Code). MOVING ' TE�. .�i `v'G-� !H .� � I,as owner of the property,am exclusively conimcting CONTRACTOR NO. . 4 f � with licensed coniracfors to construct the projed(Sec- ri c � °` � tion 7044,Business and Professions Code). ADDRE55 CONSTRUCTION LENDIfJG AGENCY -� � SE7�BACK YARD HWY T�TApROP.LINE wi�7H � � e ���' !.7" �� � I hereby affirm lhat there is a construction lending agency for FROM � n �; - the performonce of the work for whi<h this permii is issued P.L � ` `��'��� ' `�� (Sec.3097,Civ.C.). SIDE �� �.'E c�T'���. � P.L � Lender's Name ROR2 � � ��� � � ,_ LDMA Ref.# ' _ ��"� �rmit Fee �I'� , = Lender's Address -��� � � ��� P.C.Fee$ - ' - I certify ihot I have read this opplication and state thot fhe . . Issoance iee �U`�� LDMA P/C# Q above informotion is correct.I agree ro comply with all Counfy investigarion Fee /♦ —7 g ordinonces and Siate lows relafing to building construction, Total Fee�� Q7/' /'S LDMA Perm.# � � u and hereby outhorize represeMatives of this County to en er a uponfhe e-ment/io,yJ��e`dproperty inspecfion urp es. �" � � �-�� �� � -��" �� ' �"'" � ' � ��� ` . ...... . .., .� . . . . �... ... n � ��E�--��.,' ���_f��/ � . �� .. ... SEE REVERSE FOR EXPLANATORY LAhGUAGE . . .. . .._. . .. . Signature o�Appl cont or Agent"�' �.� ofe . . . . .- . .. .. .. . . �': � PLANS 70 APPLICANT INSPECTOR'S NOTES OWi1ER-RUII,DF.R DECLARATIOti � . . . . .. I hereby affirm fhat I om exempt from the Contrador's To: � � Refurned�, � �- � �icense Law foi-Ihe `ollowing reason. (Sec. 7031.5� . .. .. APProved Quaene.cs and Profc.rsions Code:An,y etitq�or rounty u�!icb No. �Dote No. Dafe - � requirea u parmif em m�sarucd,alter,im(�rone,riemnliah, . � � nr reyair any stru��ture,prior to its issuattce,.also reyairek . . t1 e upplicunt/r�r such permit to Jile a signed aratemeni� th¢t be v.��licensed yursuant ta t!e prnx:isinns oj the Con- .. .. . . . . tractor',c Limnse L.aw(Cl�apter 9f/rommencing witb Sec- � tinn 7QOOJ f L7ivdsinn 3 q/ibe Busin¢ss and Proje.csior�.c . _ ._ - . . . . . . . _ CndeJ or that fie�is exen�pt there�rom and the basrs fnr the - a/leged exeanption.�lxy violntion uf Secdion 7031.J by Required Date Received- . . . . .. . um}'aPPlicant fnr a fiermit.mhjects the af�rlicant ao u civil Approvals or ApproVed - . . . , , , , �� Qemudty nJ rent more tfiun fdve brandred do/lars($SOOJ.J: Yes No . . - .-... . . � - ` I,os owner of ihe property,or my employees with _ Water Certifimte � ����-� �� � �� �� �- � - woges�as iheir sole compensarion,will do the work,and � � �he siructure is not intended or offered for sale(Sec.7044) �� Heahh Department �-� .�- . .. �_ . .:._ .. .._:. ... � ..., Business and Prof csmxs C�e:7'he Contr¢ctor's Licenre �"- - � I um dnes nvt apply to un owner of prn/�erfy who builds Fire Department . . �- � � � or empraves thereox,and who Joes.auch wnrk bimself or . � � .. -� � � � ... .. .. ,._. througl his own �smpinyees, provided thut rwcb im- Groding - pmvements arc not intended or offered fnr sale, /f, - �� - basoea•er,tbe huilding orlrreprovemeret rs so/d u+dxbix one Geological . � .- �- - ,,,, . � �year �j completion, tFie ou�ner-builder wrll bave ehe ' ' . ., ...... � .. . � � burden�f j rm�ing tl c�a Ge did not hsseld or improve jnr Pedestrion Protection - � . _ ahe purposz of suleJ. . (Fence)(Canopy) . . � � . � . � - ❑ I,as ov✓ner of the property,am exdusively contrao- , fing wilh licensed controcfors to constru<t ihe project(Sec. Special Inspection � . � � � � 7044)Bu.��sners axd Pm/essinn.r Code:"I'Ae Contrnctnr's (Conc)(Masonry)(Welding) �� � - Licnnse 7.uu.•does not applv to an owner of property u�ho � �- � � � � ��� ��� - � builds or i»iproves tbcrvnn,and w5o contructs�/or sucA Lof Drainoge � - � � � -- , prnjvctx wieb u contractor(.cJ licewsed paarsu¢roa tn the Conbartor'.s I,eccase�Luu:J. -.. Parking _ . . . . , . . .. . . ❑ I om exempr under Sec ,B.BP.C.for this . .. .. . . ... _ ... .._ .. .... . ... . reason . � � . ..Date . . . . . _ . .. . ...,_. Owner .. . . . .._ . ..� .�. . . .. . . . . ... . . Approvals �ate Inspector's�Signatore � � ; - � � - _ � . INSPECTOR'S NOTES Location--. . . (Sefback&Yards) . Foundations �1 i S�y� ����y_..r � � , L Slab Frome � � � - . . . Energy Insulo}ion � � � � - - � - ��- � � . . . .. . . ... . . . .. ... Lath/Drywall-.- . . . - . . . . Interior "��" �� - - � � � Lath—Exferior � � - . . � House Number-- � - � --� � �� � - Correct&Pos�ed Final- � � � - � � '- Enler on froM � ' -� � �� � � � �.� 1��,� •la�i_gi�� i�/i.�z��r