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Home My WebLink About1522A 1523A .. . ,, _ _.:_ .. ...._. ..TM...,_. ,. ..�,_. WORKERS'LOMPENSATION�bECLARATIDN � � � � � � , _� - . _..,. ._ . . � � ._. . . . _ ... .. � _ . .....- . ... . . . . . .. ......_ I here6y afffrm ihaf I have p certificate of con5ent to self qpp��CAl'I�ON�� F4�t�� B,�U.r�L[�(NG �PERMIT� � � insure,or o cerlificote of Wo�kers'Compens6fion Insurance, or a certifietl copy�hereof(Sec.3800,�Lob.C.) � � �� - �� - �� 7634-$11� Pac: Indemnit COUNTY OF LOS ANGELES BUILDING AND SAFETY � PolicyNo. ompany .. y . . ._,., . . ,.... � Ce�tified copy is hereby furn�shed. FOR APPLICANT TO FILL W gunoiN� nooaess �7�'/�7�`/ �jp . ,[� Ceriified�copy�is filed with the couNy building inspec- aWtDiNG � � � n^' tiondeportment.'� ' ADORESS��JI 22979 Lakewa DriveBld . 48 �_f�, Date � ��Applicont S.McGinnis arv Diamond Bar ZiP 91765 �ocnun � CERTIFICATE OF EXEMPTION FROM VJORKERS' �� NO.OF BLDGS. NEAREST . COMPENSATION INSURANCE � � SrzE OF LOi NOW ON LOi Q � CROSS 5T. . (This se<tion need not be complefed if the permit is for one TRAcr �36346 g�«K LOi NO. A`,SESSOR�� - � hundred dollars($100)or less.) MAP 800K'� " - ' PAGE-. PARCEI TE� USE ZONE � MAP - ' `` � � I certify ihot in ihe performance of ihe work for wfiich ihis OWNER Ahmanson�Dev. -Nc8188147152 NO. ��7�-�-�- - } permit is�fssued,I shall not employ ony person�i�any monner � SPECIAL � � -. -. . a. so as to become s�bject�o ihe Workers"CompenSation Laws. - P.DDRE55 ZOOI Commerce DY.� CONDITIONS - � aTv Irwindale CA ZiP 91706 V Daie� . .�° � APPlicani �.. � . � . . ,...... � NOTICE TO F(PPLICANT-If,�after makin Yhis Cerfificate of ARCHITECT OR TEL DISTRICT GROUP NPE FIRE PROCESSED BY o 9 ENGINEER B&E En . No.213254513 -- �� Exemption, you should become subjeci to ihe-Workers' � WNSL �20NE �J Compensotion provisions��of ihe Labor Code,you must forfh- qDDRESS $25 Colorado Blvd. LA 90041 AU ,,Nti,.�e pW, with comply with such provisions or ihis permit shall be _.. . . _ . vi deemed revoked: TE�� STATISTICAL CLASSIFICATIO APT. C NDO. Z � CONTRACTOR NO. UCENSED CONTRACTORS DECLARATION . . �i� cta55 NO.�Dv�u.UNITS � - � i hereby affirm ihat I om licensed under provisions of Chopter 9 ADDRE55 23861 El Toro No.465688GBC (commencing with Sectiod700D)of Division 3 of the 8usiness and $1 Z'OTO� LIC. B_1 �'NER MAP Professions Code,and my license is in full force and effetl. CITy CLASS VALIDATION SQ.FT. NO.OF NO.OF CHECK BK' PG. License Number 465688GBC �ic.Class P'—�- SiZE 80 5rou�es pqnniuEs 4 oNe . ' .. . . - . . . . .. . VALUATION Confractor Ahmanson DOV. Do�e � DESCRIPTIONOFWORKCBT orts � NE'^' � ; ,�—��;� _ ADD � , :` 1 .�C�r'. �I am exempt under S6C. ALTER � 5 �.y o o c� a C i B.&P.C.for this rea5an REPAIR use oF �4 9 ��e' EXISTING BLDG. DEMOL � � "�� .. $ignaiure � . ... . � APPLICANT. . . ... . .� . .. .TEL . . ... . .. z vaiNr�S.McGinnis No7148612311 FINAL �-��; o � :.�:,;./!.y� OWNER-BUILDER DECLARATION _. DATE � - � - . I hereby affirm that I om exempt from�he Coniroctor's License 22900 Golden S rin s Diamond Bar � . 0 7,•j.�r--8� � Law for the follawing reason(Section 7031.5,Business and ADDRE55 l� �, FINAL ' �Professions Code�: ' ' ' - � PRESENT - ' B � � � ❑ BUI�DING Y �I'�� (a.-+. I, os owner of ihe properfy, or my employees with ADDRESS wages as iheir sole compensa�ion,will do the work�and - � - ' � � - ihe structure is not iMended or offered for wle(Section lOCauiv , =�� I .r>�'J Fi . - .7044,B�siness and Professions Code). MOVING TEL � � - - � � .� � I,os owner of the property,am exclusively contracting CONTRACTOR NO. •� ` � `� with li<ensed coniraciors to consfruct the projecf(Sec- � A�DRESS � � r�f: E, %J� tion 70J4,Business and Professions Code). CONSTRUCTION LENDING AGENCV '" � ' ��gq�� YaRD HWY TOTAPROTPPLINEFROM WI TH " " "<%1,'�J��: I hereby affirm that there is a<onsrruction lending agency for FRONT ehe parformonce of the work for which this permi�is issued P.L �] �.G�--�� (Sec 3097,Civ.C.). SIDE � . P.L. Lender's Name none S^^�V� LDMA Ref.# - Lender's Address ��- �� P.0 Fee y �C�• Pe.rnn Fee [ , � - I ceriify that I have read Ihis application ond siate thai the Issoonce Fee � l�"{� LDMA 7/G Y. � -.. . � above informafion is<orreU.I agree to comply wifh all Co�nty Investigation fee ��''" � ordinonces and Sfote laws relating to building construction, Toral Fee ��'�`� LDMA�Perm.N - and hereb �thorize representatives f fhis County to enter � � - -� � V � gna pp' gen " 3 ' J .... . _.. . ... .. . ... . .. .. .. . _. .. . ..... m upon th a e-ment on d pro rfy inspe<tion rpos � ... . .. _ .. .. . . _ � , . / ...... . .-. . . a _ `/�J SEE REVERSE FOR EXPLANATORY LANGUAGE ^ f / . _. _ ._.. . . . . . �i Si rura of A limnr or A I D te . . . . . . . ... .. . . . . PLANS TO APPLICANT INSPECTOR'S NOTES OWf�ER-BUII.11ER UECLARATION � ., I hereby affirm thot I am ezempl from the Conlractor's . . ...... ..... .. To: � � Returned � � License Law 4or the following reason. (Sec. 7031.5� � Approved Busdness anrt Profeuions Code:Any czty or county which Na. � Date No.� �OaTe�� requiras o:j�ermif to construct,alter,cmprnx�e,damoluh, � . . _., . . . _- . �or repair uny structure,/rrior Lo its issuance,also require.v . the upp/icant fr�r su.c5 permii 10 file u sdgned state»aent � � ahat fie is licansed pursumn,t to the proe�isions q/the Con- � � � . . . . . . . eractnr i�I.icense Lau�(Cbapter 9J(comnsenciag witfi Sec- tion 70Q0/a/Divisrom 3 of tfie Husiness und Prnfessions � -�� C,ndeJ nr tfiat be is exampt tberefrom and ibe bwis fnr tbe � � �� ulleqed exemption.Any+�enlation nf Sectinn 7031 S by Required Date Received� - - � � -- ' - uxy apP[icant fnr a pevxnit subjects the applicant to a civil Approvals pexalt}�oJ noi mnre thum five bun Ired dollurs(SSOOJ.J: ,. � Yes No or AppYoved� � � � - [_�� I,os owner of the property,or my employees with Wo�er Certificate � � . . . . . . . - � wages as iheir sole<ompensotion,will do ihe work,and �the siructure�s not intended or offered for sale(Sec.7044) Health Deportmeni ..._ _ �-�� ' .�. - -� � � � � - � Busixes.r and Prnfesiinxc Code:�The�Contrtictrir's Licexse �- I.aw docs not appl��to an owxer nJ proprsrly wbo bssi[d.e Fire Departmeni.. . � . or rmprnves thereon,und ip5o doe.��sucl work himsel�or . _ tbrougl /r3 uv.�n employees, prnvided tbat such 1m- Groding � � - -� pmvenzends are xot intended nr,offered/nr sa1e. If, - . - . , .. � however,tbe b:<ilding or improvement is sold within one Geologicol � . � yeur nf rompletron, tbe ourzervbuilder uill have tbe � �� .: . � .._.: � burden of(�roving that he did not Lui1d or rmprone fnr , �.. _ _. . .... :� . Pedestrian Protec�ion . � � . � � the purpose bf saleJ. � ' (Fence)(Ganopy) � � � � � I,os awner oFlhe property,am exdusively contrao- �� . �ting with I��censed contracrors Io consfruct the project(Sec. Special Inspaction- � - 7044)Business and Professions Cade;-Tbe Cantrrittnr's (Conc.)(Masonry)(Welding) - � � � �- Licexae Law daes not mpply tn axowner of property wbn - builds or improzes tfiereor+,and u�bo rotttracis fnr sucb Lot Droinage � � �� - . _ prnpects uktb a cnn6ractnr(aJ licenaed pursuaxt to the Contractor's License LdwJ: � . Parkin 9 . � ] I am exempt under Sec �,B.&P.C.for this ..� reason .., ..._ . � � Date Owner Approvals� Date Inspecfor's Signature. � . � ' �' ; . INSPECTOR'S NOTES � Lomliorv- .�� (Selback&Yords) Foundations � � .h 1 . � .�. .. �. . � .... .... . .. . . �l i�\o II I 1� ( (1��.i--"' . . .,.. . . . . _ . . _.... . Slab . .. _ . . . .. ._. . . .. .. . _... .. . Prame . � � �� Energy Insulation . �. . . . ... . ._ .. .,,._ __ ..�.n�.:.��..., . Lath/Drywall-..._ .. .. . . . .. . .. . . ..... ... . .. ... ...... .. ..�. In�erior Lath--Exterior � � � Hause Number-- � � -�- - - -� Correct 8 Posted - Final� . - . . . . .. � . . .. � . . .. . . ... � ..,.... . En�er on Front � ,� �y ) . .. . .. ... - �. . ._ .. . .. . .. , .. �+.lk:t•i.�. ��-1:.5�.; �� ':��9--- � . .. .