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HomeMy Public PortalAbout4918 ARDEN DR_Building_9/3/1982_reroof WORKERS' COMPENSATION DECLARATION II hereby affirm that I have a certificate of consent to self A P P L I CATION �F O R BUILDING PERMIT L� insure, or a Certificate of Workers'Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ti c�c 00400-10637ea Poli y o. mpany Argonaut Tnc_ BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 451 c ® Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 4918 Arden Dr. LOCALITY NEAREST Dare 11-1-81 Applicant Howard L. Randol CITY Temple Cit zip 91780 CROSS ST. - CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. 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 hundred dollars ($100)or less.) TRACT BLOCK LOT NO. - NO. TEL �� SPECIAL I certify that in the performance of the work for which this OWNER avid rim NO. - CONDITIONS O permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROC SSED BY U so as to become subject to the Workers'Compensation Laws. ADDRESS n.� CON . ZONE /'� IM Date 8-31-82 Applicant Howard L. Randol CITY Temple City zip. 91780 U STATISTICAL CLASSIFICATION APT. CONDO. CJ NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. tL ENGINEER NO. CLASS NO.�_DWELL. UNITSCL Exemption, you should become subject to the Workers' v) Compensation'provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with, comply with such provisions or this permit shall-be deemed revoked. CON�Waxd L. Randol lnc. No.288-4040 BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter ADDRESs529 E. Valley -Blvd. NQ.186086 VALUATION (commencing with Section 7000)of Division:3 of The Business and LIC. Professions Code, and my License is in full force and effect. CITYSan pbrii-1CLASS - $ 1175.00 186086 C-39" SQ. FT. NO. OF NO. OF CHECK , License Number: Lic. Class SIZE STORIES FAMILIES ONE ContracloOWBYd L. Randol Date 8-31-82 DESCRIPTION OF WORK NEW [J $ - ADD I am;exempt from the licensing requirements as I am a licensed architect or a registered professional engineer ALTER FINAL acting- in my professional capacity (Section 7051, 12X18 compo. shingles. El DATE Business and Professions Code). USE OF REPAIR EXISTING BLDG. DEMOL FINALI z6 0.4,7 A Lic.or Reg. No. Date APPLICANT TEL. . OWNER-BUILDER DECLARATION (PRINT NO.988-4040 a( t # O'010 0 0 1' I hereby affirm that I am exempt from the Contractor's License 529 E. Valle Blvd. SG Law for the following reason (Section 7031.5, Business and ADDRESS y V . . G. kl( , ,2'o -.43,00 Professions Code): PRESENT ❑ BUILDING 'o o o 43, 0 06 I, as owner of the property, or'my employees with ADDRESS , wages as their sole compensation, will do the work and 019. 0 3'-82 the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS" tion 7044, Business and Professions-Code). REQUIREDTOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 1 hereby affirm that there is a construction.lending agency for FRONT the performance of the work for which this permit is issued PA (Sec. 3097,.Civ. C.). SIDE P.L. Lender's Name 'J Pt C. Fee$ Permit Fee - Lender's Address w 1 certify that I have read this application and state that the Issuance Fee 8.50 above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws.relating to building construction, g Total Fee ��- 715ro_ m and hereby Authorize reprsentatives f this County to enter U upo the ao m oned pro er1 r inspection poses. a - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicantp6r Agent Sate ©s