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HomeMy WebLinkAbout7181AWORKERS' COMPENSATION DECLARATION r� r� I ,�'iereby affirm that I have a certificate of consent to self PERMIT`PLICATION FOR BUILDING insure, or a certificpte of Workers' Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policyl\Iq4PPI '3-'17UmP anyIndllstriAl Indemn' Certified copy is hereby furnished. aCertified copy is filed with the county building inspec- tion department. Date 4-15-81 Applicant'Arciero & Sons CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one 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 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 329595 Lic. Class B-1 Contractor Art' i err Fv SOn4Mate 4-15- I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer acting in my professional capacity (Section 7051, Business and Professions Code). Lic. or Reg. No. _Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): ❑ 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 sale (Section 7044, Business and Professions Code). I, as owner of the property, am exclusively contracting 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.).. Lender's Name Homestead Savings & Loan Lender's Address 1777 Murchison Dr, Bllrli I certify that I have read this application and state that the nga: above information is correct. I agree to comply with all County CA 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. FOR APPLICANT TTOFBLDG BUILDING ADDRESS BUILDING ADDRESS LOCALITYr NEAREST CITY CROSS ST. NO. ASSESSOR SIZE OF LOT NOWMAP BOOK PAGE PARCEL USE ZONE MAP TRACT BLOCK O. NO.� t SPECIAL TEL OWNER CONDITIONS 20001 E. Walnve DISTRICT GROUP TYPEFIRE PROCESSED BY ADDRESS CONST. . ZONE CITY Wa lnut CA 7 8 9( STATISTICAL CLASSIFICATION APT. CONDO. ARCHITECT OR ENGINEER — CLASS NO. (i'" "' DWELL. UNITS .. ADDRESSNu- TEL. CONTRACTORArclero & Son NO.598-1 ADDRESS20001 E. Walnut Dro.32959 LIC. CITY SIZE -FT 934 STORIIES N6 OF 2 AMILLIIES OF WORK USE OF EXISTING BLDG. APPLICANT TEL. (PRINT) Arri P-rn k gr7T1S NO. ADDRESS MOVING TEL. CONTRACTOR NO, J_ CHECK ftEW ADD ALTER REPAIR DEMOL REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. SET BACK PROP, LINE WIDTH FRONT P. L. SIDE P.L. P.C. Fee $ Permit Fee Issuance Fee Investigation Fee Total Fee JtWtK MAY BK. PG, VALIDATION VALUATION $ 1�R A 110,152.00 I ' /1- 1 `), c' 0 FINAL Ll O cS DATE FINAL O & By Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE ©5