HomeMy WebLinkAbout6486A 6487AWORKERS'COMPENSATION DECLARATION
I herebyaffirm that I have a certifimte o,consent l0 5a f - qpp CATION FOR BUILDING PERMIT ,insure,or a certificate of Workers'Compensation Inwrance,
ro cenifiad copy rhe.eof sa.3soo,iob.C.) COUNTY OP LOS ANGELES BUILDING AND SAFETY
rou YNo. PWCC2337„Y Pacific Employers
Ce rcfied copy is hereby fumished. APPLICANT TO FILL IN sw o Nc j`7 / 0ADDRE55IJ((r"7 i,-Yjv--r'
Certified mpy is filed wit munty ilding inspec-gUIL ING
fion departmenL' ADDRE55 r Summitridge Drive
oo e 3/18/86 .qppl con arr Diamond Bar, CA ZiP 91765 OCALITY
CERT FICATE OF EXEMPTIO F OM WORKERS' NO.OP BLOGS. NEAREST
COMPENSATION I RANCE SiZe OF oi Now ON OT —O— Ceoss ST.
ihis secfion need noh be completed if ihe pe mit is for on ' TRACT 42559 B OCK LOT NO. 2 rJ ASSESSOR
hundred dollars($700)or less.) MAP BOOK PAGE PARCEL
TE. US ONE POWNERM.J. Brock & Sons, In.529-8170 ,y3fyIcertifyihafiniheperformanceoftheworkforwhichihis NO. y
permit is issued,I shall nof employ any pers6n in any manner P.O.-BOX 3SO - q SPECIAL Q
so as to become:subject to theWorkers'Compensation Laws.AooRE55 L. coNoinONS v
n; ;; , aTv Brea, CA 92622 ziaDafeApplicant' '- ' ' ARCHI7ECTpR TEL. QNOTICETOAPPLICANT:If, after making Ihis Cerlifimle of ENGINEER 1.C. Ma'or & E SSOC. NO.62-8177 DISTRICT GROUP NPE FIRE_! PROCESSED BY ,H
Exemp ion, you skould become subject to the Workers' ' CONS fhwx' WComoensationprovisionsofihaLoborCode,yo must forth-aooneSS 10841 S. Paramount /Ve. Downey
with comply wiih such provisions or,this permir shall be y
deemed.revoked:., FIRer TE STATISTICAL CLASSIFlCATION AP7. ONDO. ZCONTRACTORNO.
LICENSED CONTRACTORS DECLARATION i . , . C aSS NO. DWEu.UNiTS
I hereby affirm that I am licensed under provisions of Chapter 9 AD RESS NO.
commencing with Sedion 7000)ofDivisioh 3 ofihe Businessand , _, SEWER MAP
Professions Code,and my license is in full force and effect. CITv CLA55 VAIIDATiON
54.FT.NO.Of NO.OF CHECK BK. PG.
Lirense Number 54648 ;.cioss Bl s ze 3259 sroKies -2 Fnnniues 1 oNe .
VAlUAT10N
Conimctor Date DESCRIPTION OF WORK new 5117 le famil NEW G l],
ADD s 164,400.00
i am ezempt under Sec. Wlt}1 1tt3Clle[L ara e a S;A a i
ALTER
B.BP.C.for this reason REPAIR ; i o ''2 fJ'
Date: USE OF
v
E%IS71NG BLDG. N A DEMOL d -2 S,
Si nature APFLICANT TEL. g
OW BUILDER DECLARATION PRINT)M..I, Brock & Sons No.529-8170 DAE i4,:' Q'- ;'
I hereby offirm iho I m exempf from ihe CoNroc.or s License P,Q, $OX 350 Br.ea C,L 927ZZawforthefollowmgieason(Section 7031.5,B iness and AooRE55 e FINAL
Professions Code):PRESEN BY .",p^;},h?•'.?; OBUILDINGI, os owner of the properly, or my employees wifh ADDRESS
woyas os t{-ei sole mrr pen aolon,wlll oo ine wu k ond
LOCALITY z J.5..! Ftheslrclureisnolintendedorofferedforsale(Sacfion
7044,Bosiness and Prafessions Code).MOVwG iei.
CONTRACTOR NO. d I,as owner of Ihe property,am exclusively contraciing
with licensed contractors to consfruct fhe projeci(Seo- AD RE55 7.L,}Jtion7044,Business and Professions Code}.
CONSTRUCTION LENDING AGENCY REQUIRED yqRD HWY TOTAL SET6ACK fR I T.
SET BACK PROP.LINE WIDTH n,(jIherebyaffirmthpithereisaconstructionlendingagencyforFRONT
the performance of the work for which this permit is issued p.i.
Sec.3097,Civ.C.). SIDE
Q i!.:
3 P.L.
Lender's Name None
LDMA Ref.H
Lender's Address P.c.Fee$ 432.87 Permir Fee 727.5
I cenify ihat I have read ihis application and state that ihe . issuon<e Fae 10•50 onM PiC K
c above information is correcl.I agree to comply with all County investigation Fee
ordinances and Stare laws relming to building consirudion, To ai Fee 738, LDMA Perm.# and herehy aulhorize representatives of this County to enter
up he abo i -m.ntioned property for inspection purposes.f LllMA = $109. LDMA = $55.
3/18/86 SEE REVERSE FOR EXPLANATORV LANGUAGE
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