HomeMy WebLinkAbout1508A 1509A (13)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a ceRrrtified copy thereof (Sec. 3800, Lob. C. f
Policy Ro �I 956-1L4mpanA FritQA
ri Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion deportment.
Date 1/21/84 Applicant TRF ➢TTI'JNT t^_pf1T3p
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (=100) or less.)
1 certify that in the performance of the work for which this
permit is Issued, I shall not employ any person in any manner
tons to become subject to the Workers' Compensation Lows.
Dote Applicant -
NOTICE TO APPLICANT; If, after making this Certificate of
xemption, you should become subject to the Workers'
-ampensatlon 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 '271 RRfT tic. Cl.--B-
Contractor
lan $Contractor m11F. AMEN C,-RQIIP_Dotr/23/2A._
13 1 am exempt under Sec.
B.&P.C. for this reasor
Signature
OWNER -BUILDER DECLARATION
I hereby affirm shot I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
fP'r�ofessions Code):
J I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sole (Section
7044, Business and Professions Code).
C] I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec.
tion 70", 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
1 certify that I have read this application and state that the
above information Is correct. 1 agree to comply with. all County
ordinances and State lows relating to building construction,
and hereby authorize rep' sentatives of this County to enter
u he above -mention property for inspection purposes.
Signatur f Appli nt or A M � Date
1� B APPLICATION FOR BUILDING PERMIT
ANGELESCOUNTY OF LOS SAFETY
SEE REVERSE FOR EXPLANATORY LANGUAGE
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FOR APPLICANT TO FILL IN
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24250 SEAGREEN DR
ADDRESS 242
LOCALITY T)TAMCM ]BAR
NEAREST
CITY
ZIP
CROSS ST.
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT
NOW ON LOT
MAP BOOK PAGE
PARCEL
TRACT 33020
BLOCK LOT NO.
22
USE ZONE
NpP -4
TEL.
SPECIAL
OWNER
NO.
CONDITIONS
DISTRICT GROUP FIRE
PROCESSED BY
ADDRESS 1074 PARK VIEW DR.
CONZO
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CITY
ZIP
STATISTICAL CLASSIFICATION
APT. CONDO.
ARCHITECT OR--
TEL
TO
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E INFER
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CLASS NO, DWELL. UNITS
ADDRESS
SEWER MAP
TEL
-
Pr"
VALIDATION
CONTRACTOR
NO.
LIC.
ADDRESS
NCL
VALUATION
CITY
CLASS
B
s64,850
SO. IT,
NO. OF NO. OF
CHECK
SI//Z��Ep
STORIES FAMILIES
ONE
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WORK CONSr1=ION
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ADD
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FA=Y HQ�MS
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FINAL
2 1 5 Q 8 A
REPAIR ❑
DATE lj(94
USE OFMMOL
EXISTING BLDG.
C1FINAL
8v .(A�_
9 • • • • 21
SEE REVERSE FOR EXPLANATORY LANGUAGE
01
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••223136
0213-84
V 5Q9A
1 •385.50
e -385.506
0213-84
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