HomeMy Public PortalAbout10544 DANBURY ST_Building_8/12/1983_reroof WORKERS' COMPENSATION DECLARATION /� �(/� M FOR Irl
hereby affirm that haver certificate of consent to self /O\ PPUCAYM V Il OR � UOLON Pf�G�nNT LI IS
insure, or a certificate of Workers' Compensation Insurance, (/'l1 IS .
or o certified copy thereof (Sec. 3800, Lab. C.)
Policy No.-c c 20-4k�mpb46.327 Argonaut Ins . COUNTY OF LOS ANGELES BUILDING AND SAFETY
Ctshed. FOR APPLICANT TO FILL IN- ADDRESS
ertified copy is hereby,furn
Certified copy is filed with the county building inspec- BUILDING
tion deportment. ADDRESS 10.544' DanburyLOCALITY
Randol .Roofi4g & Cons NEAREST
Date 11;-1=8 applicant CITY 'Temp 1 e City, ' Zip 917_8 0 CROSS ST. a
. CERTIFICATE OF EXEMPTION FROM WORKERS' . . - - -NO.OF BLOCS.-- - ASSESSOR
COMPENSATION INSURANCE ; SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if,the permit is for one - USE ZONE MAP G
hundred dollars ($100)or less.) , . TRACT BLOCK - LOT NO r NO. 6 -
- -
TEL -SPECIAL
I certify that in the performance of the work for which this OWNER E.11Zab,t11. .Gorman NO: 444"-657 'CONDITIONS - d
permit is issued, I shall not employ any person in any manner DISTRICT .GROUP TYPE FIRE PROCESSED BY O
ADDRESS. 10.544 Danbury CONS z E u
so as to become subject to the Workers'Compensation Laws. =
CITY .Temple City, `ZIP - 9.1780. Q O
Date Applicant STATISTICAL CLA t TION - APT. ON V
NOTICE TO APPLICANT: If, after making this,Certificate of ARCHITECT OR TEL.
ENGINEER NO. CLASS NO. DWELL. UNITS_ W
Exemption, you should become subject to the Workers' tl
Compensation provisions of the Labor Code, you most forth- gDDRESS SEWER MAP a
with comply with such provisions or this permit shall be Randol 00 til QLS,n
deemed revoked. p g BK. FIG, VALIDATION
CONTRACTOR .. NO. -
LICENSED CONTRACTORS DECLARATION LIC_
I hereby affirm that I am licensed under provisions of Chapter 9 S 2 9. E Valley.ADDRESS NO, 1 8 6086 VALUATION-
(commencing with Section 7000)of Division 3 of the Business and San Qhhr i e 1 .91776 LIC' _ $
Professions Code, and my license is in full force and effect. CITY CLASS _ 1 0.9'2, 0-0 D
1860,86 C-3 9 SIZE STOROES AMIDES GONERS
License NumberLic Class
Randpl Roofing & COns.t . --7-27-83 DESCRIPTION OF WORK Re-sroof house NEW ❑ $
Contractor Date _ _
I am exempt under Sec. - and garage with. 12-XI
ADD ❑
Com s, 1n e.. ALTER ❑ FINAL
B.BP.C. for this reason p g n DATE G,IK,� ��S
REPAIR 4U
USE OF FINAL
Date: EXISTING BLDG. DEMOL. ❑ By
Signature APPLICANT an O oo ing T .ORS- Y
OWNER-BUILDER DECLARATION PRINT NO. -288,.4(14Q
I hereby affirm that I am exempt from the Contractor's License gDDRE55 529. E. Valley -' D #RA 14 -19
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT2,e ° 49.88
❑ BUILDING ,
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and I-'-
p.
the structure is not intended or offered for sale(Section LOCALITY o o a 4 9885
7044, Business and Professions Code). MOVING TEL. o
I, as owner of the property, am exclusively contracting CONTRACTOR NO. .0 8, 1 21-83
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044; Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST..
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH D
I hereby,affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.I.
(Sec. 3097, Ci, C.). SIDE
P.L.
Lender's Name
$ Lender's Address P.C. Fee$ Permit Fee 39 38
I certify that I have read this application and state that the Issuance Fee S O.
above information is correct. I agree to comply with all County Investigation Fee
g ordinances and State laws relating to building construction, Tocol Fee 49 . 88
'
u and hereb authorize representatives of this County to enter -
9' upon t �ba�ve--m�/e/n�ned o/pe�µy' forr in�p/e/tion pu poses.�
e �r/!�f/f/A /NYJZ+LL(`YO i SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or AgentDate ®s
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