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HomeMy Public PortalAbout4935 ARDSLEY DR_Building__ WORKERS'COM.F NSATION DECLARATION I fare firm tli t I have a certificate of consent to self DOD D O O D * rasvte or d rertifica! of Workers' Compensation Insurance, " lL/'11 L1 F��CAU�O LI M V FOR or a certified copy therpof (Sec-��3600, Labs.) r 01 BOLDING OF LOS ANGELEBOLDING ASD SAFETY Policy No. Company ; Certified,copy is hereby furnished. BUILDIN FOR-APPLICANT 1f ILk,AN . G .J ❑ �V. ADDRESS Certified copy is filed with the county building inspec- BUILDING p C rt/ tion department. ADDRESS. 5` L C 1 ( LOCALITY- �/ NEAREST'. 4i Date Applicant Y' CITY- CI`( PL_E-CI I Y ZIP 1 g� CROSS SL - CERTIRCATE OF EXEMPTION FROM WORKERS', NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT IZ NOW ON LOT ! MAP BOOK PAGE ' PARCEL This section need not be com leted rf fhe ermit is for one r t USE NE MAP Hundred dollars'($T00)or,less') P TRACT'(4 BLOCK LOT NO I NO. / �� SEC: SPECIAL (''certify-That in the performance=of the,work.for which,fhis OWNER (_ iI�.ItOCQt�I ' " CONDITIONS" IL permit is issued, I shall not em oy any erson in ny manner DISTRICT G OUP TYPE FIRE PRO SSED BY so^as to become subject to the rker Co ADDRESS 5 r-6 Q~ /(��p CONST ZONE 4J CITY ZIP R "� (J©, '5 2C ®'' Im Dat Applica STATISTICAL CLASSIFI TION APT, COPbo. F NOTICE TO APPLICANT:-.If after,making thioCerti icate of ARCHITECT OR TEL. f� Exemption,,you should become' subject. the Workers` :. ENGINEER NO: LU SS NO Compensation provisions of thCL e Labor Code, you.must forth-: rA . ADDRESS = CSEWER MAP ; DWELL UNITS with comply. with such provisions or this-permit.shall:be �? Z deemed revoked.. K C T.pG . VALIDATION ^� (('7] TEL. CONTRACTOR L,t(�. NO.. B LICENSED'CONTRACTORS DECLARATION LIC. ; I her affirm that I am licensed under-provisions of-Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. ' Professions,Code, and my license is:in full force and:effec{: CITY •'. : CLASS $ SQ. FT.. NO. OF NO.OF CHECK D License Number Lic.Class SIZE / STORIES FAMILIES- ONE • a DESCRIPTION OF WORK }/ / + Q" NEW 0 $ Contractor.- Date 1l I am exempt under Sec - R�Ti3 b' f? 34p ADD . o �'7O4,:9 r, ALTER FINAL. # 0 0 0 0 2-3 BAP.C. for this reason 'JT pt�.• - t I o 275.:x'8 3 , DATE • REPAIR ❑ ^' USE OF Dater 1 -".�1 //••r FIWA :_ o .e S2 _ EXISTING BLDG. L5 1 L H-C1 ] /�'f'✓Q .DEMOL,,.❑ Signature APP PR NT) I�L L (�aNO.Z� p� lJ By01 y 1] Jr "OWNER-BUILDER DECLARATION'. I hereby affirm that I am exempt from the Contractor's License (�,-ss AIR : Law,for the following reason (Section 7031.5, Business and ADDRESS —1 J A It P ofessions Code): PRESENT. BUILDING G I> as owner of the property, or my employees,.with - ADDRESS wages•as their sale•compensatton,will do the work'and . th'e''strucfure is'not'nfended.oroffe�ed foi sale,(Sectiori LOCALITY" : 704,1+B'usin"ess and Professions Code) MOVING TEL ❑ ``,� CONTRACTOR -NO. I, as-owner of The property;�am•exclusrvely contracting + with licensed contractors,to','construct the "ro'eeT Sec- P, L ( tion 7044, Business and Professions Code,) ` ADDRESS" A REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 7 3 5.12'A I hereby offirm`that there is:a construction,lending agency for 'FRONT. the performance of the work for which this permit is'issued P.L. (Sec. 3097 Civ. C ).. '.SIDE (,:0 3 '.0 Q' P.L: v Lender's Name - 0.0 2 Y �. P.C..Fee$ .Permit Fee• S n ...o Le er's Address �L�rJ �� v ° '� 2 7 a v I c rtify that_I read this application and state.that the ISsuance Fee (�t a e inform ion correct I agree to.comply•wlth.all County Investigation Fee S o_ nances a d St a laws relat'ng to'building'constructjon, x n•. "•- a her4by e:re)irese tives,of this.County to enter, iota) e. . u n the, Ve n toned p ' rty for inspect'on purposes. o ��l r SEE REVERSE FOR EXPLANATORY LANGUAGE Signatu f Applicant gent - Date