HomeMy WebLinkAbout0607 8196AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate. of Workers' Compensation Insurance,
or o certified copy thereof (Sec. 3800, Lab. C.)
Policy No. 86490 Company FAIRMONT INS.
13 Certified copy is hereby furnished.
Certified copy is filed with the coul+ty building inspec-
tion depaprtmlent. /
Dara I'1 / U Applicant
CERTIFICATE OF EXEMPTION FR M)k3%KERS'
COMPENSATION INS ANCE
This section need not be completed if the permit is for one
hundred dellors IS100) or less.)
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.
Dote Applicant
NOTICE 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 I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 283724 Lic. Class B1
Contractor. PIERMARINI ENT. Date 8
1 am exempt under Sec.
BAP,C. for this reason
Dote:
Signature ,
NER-BUILD DECLARATION
I hereby affirm 41hat I am exempt from the Contra-foi s License
Law for the following reason (Section 7031.5, Business and
Professions Cade):
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, as owner of the property, am exclusively contracting
wlth licensed contractors to construct the project (Sec.
tion 7044. Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I terrify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and Stare laws relating to building construction,
and hereby oGihorize reprrsr, nlariYes of this County to enter
upon the abbve•montioneof pr petty icy inspection purposes.
4uil/i.
S §nwr of Aipipli m or Agent /Dote
APPLICATION FO I ' BUIL'DINGs`PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDINGADDRESS 754 PENARTii AVE.
BUILDING
ADDRESS 754 PENARTii AVE.
CITY WALNUT zip 91789 LOCALITY
NO. OF BLDGS. NEAREST
SIZE OF LOT NOVI ON LOT CROSS ST. LYCOMING
ASSESSDR
TRACT BLOCK LOT NO. MAP BOOK I PAGE PARCEL
OWNER MOLD—TECH NO595-7494 USE ZONE_ APNO.
754 PENARTH SPECIAL
ADDRESS CONDITIONS
CITY WALNUT ZIP 91789
ARCHITECT TEL.
ENGINEER IERMARINI/JOHNSON No.594-4800 DIST , GROUP OPEC
r v A
EICtPROCESSEDBY
ADDRESS ^ 1-2-
PIERMARINI ENT. TEL 594-4800 STATISTICAL CLASS'FICATION APT. CONDO.
CONTRACTOR NO.
CLASS NO.. LNELL. UNITSUC.
ADDRESS 770 PINEFALLS NO.283724
LIC.
CITY WAT.NITT CLASS R1BK.
SE44TR MAP
VALUATION
s 60,000.00
0 U,0
VALILOlT10
2 3
1 2 9 9 5
2
SO, FT. NO. OF NO. OF
SIZE STORES FAM.ILIE.S CHECKONE
DESCRIPTION OF WORK NEW
ADD
TENANT IMPROVEMENTS
S 0328— 9
ALTER
REPAIR
USE OFEXISTING BLDG. CEMOL
FINAL / 90DATE1(
APPLICANT TEL. 7!Y
IPR'NT K t AN x-epRINO.
ADDRESS 7747 .SO. Z:Z 4LJ-- Lr/RL vy-
By `•t C(s
BUILDINGADDRESS 1 O, 6 A
LOCALITY
N e 4 9 7, OVI TEL. NO. c
X497.5"i
CONTRACTOR
ADDRESS 0627— O
SET YARD HWY I(,IIA PROP. LINE y'L WIDTH
FRONT
P 1.
SIDEP. L.
LDMA Ref. Mr4/
P.C. Fee S Permit Fee .r3
Issuance Fee /' ew LO., P!C Y
Invest gae,on fee
JJITotalFee IDM,A Perm. N
SEE REVERSE FOR EXPLANATORY LANGUAGE
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