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HomeMy WebLinkAbout7180AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compenstion Insurance, or a certified copy thereof (S6e6. 3800, Lab. C. ) Policy QB813-37 CompanyIndustrial Indemn' ® Certified copy is hereby furnished. OCertified copy is filed with the county building inspec- BUILDING tion department. ADDRESS APPLkATION FOR BUILDING PERMIT lj COUNTY OF LOS ANGELES BUILDING AND SAFETY BUILDING FOR APPLICANT TO FILL IN ADDRESS Date 4-15-81 ApplicantArciero & Sons [ADDRES iamond Bar CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE OT (This section need not be completed if the permit is for one BLOCK hundred dollars ($100) 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.Date Applicant alnut, CA T OR NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be deemed revoked. CONTRACTOR LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. CITY SQ. FT. License Number 2 2 9 5 A Lic. Class B-1 SIZE 4762 Contractor Arclero & SQmae 4-15-81 DESCRIPTION OF I am exempt from the licensing requirements as I am a non licensed architect or a registered professional engineer acting in my professional capacity (Section 7051, Business and Professions Code). USE OF EXISTING BLDG. Lic. or Reg. No. Date APPLICANT LOCALITY NEAREST ZIP CROSS ST. NO. OF BLDGS. ASSESSOR I NOW ON LOT MAP BOOK PAGE PARCEL USE ZONE MAP LOT NO, NO. SPECIAL TEL. NO-598-1 2 CONDITIONS DISTRICT GROUP FIRE PROCESSED BY fPE NST. ZONE 91789 zip STATISTICAL CLASSIFICATION APT. CONDO. TEL. NO. CLASS NO. DWELL. UNITS — L Irvine SEWER MAP Elm N L. -18 2 BK. PG, VALIDATION LIC, allt NO. 2 VALUATION ASS i �'' 0 ANO. 7PQc $ 13 3 3 3 6. 0 0 '' OF , -- CHECK fit' `e ` FAMILIES, _ ONE ' un—it NEW ® $ ) Q f 0 ADD �� © (_� U, ALTER FINAL REPAIR ® DATE i' DEMOL ® FINAL By TEL. OWNER -BUILDER DECLARATION (PRINT) NO. 598-182 I hereby affirm that I am exempt from the Contractor's License ADDRESS 20001 E . Walnut Dr, Walnut Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT mom I, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section LOCALITY 7044, Business and Professions Code). MOVING I, as owner of the property, am exclusively contracting CONTRACTOR with 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. ). Homestead Savings & LoanLender's PADDR Name Lender's Addressl777 Mnrnbison _RnrI i ngame,I certify that I have read this application and state that the CAabove information is correct. I agree to comply with all Countyee ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above -mentioned property for inspection purposes. Signature of Applicant or Agent Date TEL. NO. YARD HWY TOTAL SETBACK FROM EXIST. PROP. LINE WIDTH Permit Fee Issuance Fee Total Fee SEE REVERSE FOR EXPLANATORY LANGUAGE 4 L- q' y3