HomeMy Public PortalAbout9186 JAYLEE DR_Building_8/3/1989_re-roof WORKERS' COMPENSATION DECLARATION
insure,oraaffirm
certif certificate of Wo ke s', Compensat on Insurance,
USE ZONE, MAP.
I certify that in the performance of the work for which this' G NO.
permit is issued, I shall not employ any person in any manner. ADDRESS tf d .�j�y��E �j� SPECIAL - a
/� CONDITIONS
so as to become.subject to the Workers'.Compensation Laws. r Y nN 0
/ p/�) CITY ��� C f r( - (�,+:_-ZIP Ff 17Kd U
e Date � Applicant_l l(L�/ �r/ � - ARCHITECT OR ' TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0
NOTICE TO APPLIC NT:,If,.-after makingthis tertificate of ENGINEER NO.
CONST. ZONE
Exemption, you .should become subject'to'the 'Workers' ` ' w
Compensation provisions of the,Labor Code, you must,.forth- ADDRESS 3 p
with com I with such provisions or this STATISTICAL APT. CONDO. N
ply p permit shall be TEL / Z
deemed revoked. CONTRACTOR N _
LICENSED CONTRACTORS DECLARATION. C.
CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed,under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business -
LIC. SEWE MAP
and Professions Code,and mylicens ,is in full force and effect. CITY CLASS gK PGq VALIDATION
SQ. FT. NO. OF' NO: OF {HECK
License Number Lic.'ClassSIZE' I STORIES FAMILIES ONE
'VALUATION
Contractor Date w
DESCRIPTION OF WORK NE ❑ $ L G nJ
ADD
❑'1 am exempt under'Sec.`' _ ® ❑ l/ D
ALTER ❑
B:&P:C. for this reason' $
REPAI -
USE OF
Dater LDG. DEMOL
EXISTING-B
Signature APPLICANT TEL FINAL"
:OWNER-BUILDER DECLARATION DR
PRINT), " NO.
I hereby affirm that I am exempt from the Contractor's License
DATE/
Law for the fall owng;aeason (Section 7031.5,.:Business`and ESS TINA
Professions Code): PRESENT. 13y. rr
BUILDING ACC A '
1, as owner of the property, or ,my employees with ADDRESS
NRI
wages astheir sole compensation,will do the:work and - L .
the structure isnot intended or offered for sale(Section LOCALITY ' �U7 QVe 3.
7044, Business and Professions Code:)• - MOVING TEL. D - ITEMS
E] 1, cis owner of-the property, am exclusively contracting CONTRACTOR NO. --o
with licensed contractors to construct the project (Sec- - - TOTAL 63 o.6 °6
tion 7044, Business and Professions Code.) ADDRESS cru t[ L[
REQUIRED _.TOTAL SETBACK FROM EXIST:: CHECK OJ.oO'
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirmthat there is a construction lending agency for FRONT CHANGE o{ ]�
the performance of"the work:for which this permit is issued P.L.' -
(Sec. 3097, Civ. C.). SIDE
Lender's Name, 0000_0001
U� jlti
S( LDMA Ref._ . Q��-700"Qt0{ry0's 1
P.C. Fee$ Permit Fee UU �Vt!/ i AM :22j4
Lender's Address -
o I certify.that I have read-this application and state that the Issuance Fee V r LDMA P%C,ti
o -
8 above,information is correct. I agree to.comply with all,County Investigation Fee.
R ordinances and State laws relating to building construction, Total Fee' !94/ LDMA Oerm. q -
a and hereby authorize representatives of this County to enter
hea ove-me d property for,inspection purposes:
2' up t
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App cant or Agent Date'