HomeMy Public PortalAbout9171 BIDWELL ST_Building__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to ,elf APPLICATION '.FOR. BUILDING P E RM I T
Insure, or a certificate of Workers'Compensatlon Insurance,
or a certlfled copy thereof (Sec 3800, Lab..(.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. 104614D company .State Fund
❑ Certlfled copy is here fumished. . FOR APPLIEAI�lT TO FILL IN BuILDIrIG
RY by ADDRESS 9171 Bidwell, T. cy. . 91780
® Certified copy Is filed with the county building Inspec- W LDING
Mon department. ADDRESS
Dote L1-1-90 Applicant Randol.Roofiiig CITY T.0 ZJP 91780 LoCAM
NO. OF BLDS& NEAREST
CERTIFICATE Of D(EMpTION fROM WORKERS' SIZE OF LOT NOW ON LOT dZOSS$s,:
COMPENSATION'I NSU RANCE ASSESSOR
(This section need not be completed if the permlt Is for one TRACT BLOC]( LOT NO. /yUp BOOK PA_GE PARCH.
hundred dollars (;100}or less-) TEL
."DR 1 -Van Dreist - No:314-576-9'9. � " -� 2 G S
I cartffy that In the performance of the work for which this
.permit Is Issued, I shall not employ any person In arty manner ADDRESS 12714 Wi_LloWyck •75 —,I SPECIAL
so as to become subject.to,the Workers'Compensation Laws- COfDffK)tN5
t.
Date 8-29-90" ENGINEER NO.- D GROUP TYPE RE BY O
ApplIcpnt Randol RoofiTig ARai�r Loui9. LP- 63146
re.. oc
NOTICE TO APPLICANT: If, after making this Certificate of oONST ZONE
Exemption, you should become. subject to the Workers •.
Compensation provisions,of the Labor Code, you,must 4orth ADDRESS
with comply with sgch,provisions or this perrrltt shall beTEL STATISTICAL CLFti55lF4CATFQN APT. CONDO,
deemed revoked. _ oot�TRAcroRRandgl Roofing 288-4040 Z_
LICENSED CONTRACTORS DEQARATIorI ADDRESS Valle Blvd Ljr_t4o1937 CLASS NO. UNITS
I hereby affirm that I am licensed under prov'Wons of Chapter 9 SEWER MAP
(commending with Section 7000)of Division 3 of the Buslnan San Gabriel, Ca. C-39
and Pr9fasslonk Code,and my license Is In full force and effect. CITY' CLASS BK PG. VALmAnON
SQ. Fr. NO. OF NO.OF CHECK
License Number 451937 He Classes 39 Sta sTORLEs EAMLIEs org
VALUATION
.Contractor RandI. Roofing� 1-31-92 DRIP IoN OF WORK Re--roof- house and rtw ❑ $ 1900.00
m exempt
❑I aunder sec- garage 'withDo
. GAF Timberline - A ❑ ,
- B.BP.C. for this reason ❑
fiber las"roofiz<g: . (lase A. . REPAIR ® $
o�am�NG BLDG. Sfd Roof nEn+oL ❑
Signature- 'ter Randal Roofing Ts 288-4040 ' --FINAL
OWNER-BUILDER DECLARATION ��
I hereby affirm that I am exempt from the Contractors License
Law for the following reason (Section 7031.5, Buslnbss and ADDRESS 529E: Valley Blvd. S.G.. - 91176:
FINTdy
Professions Code): PRESENT -)Ir r/
1
❑ I, as owner of the property, or my,employees'with AADID�NG X.CT.ir.
wages as their sole compensation,will do the work-and LOCALITY • . - .-- - _ . . .. — - —q-- � �7. 70.38
the structure Is not intended or offered for sale(Section
7044, Buslnees and Professlons Code.) - Mb� " TEL. -
❑ I, as owner of the property, am excluslvely contracting �� �' —- T1 y11.I� �7
with licensed contractor} to construct the project ($ec- ADDRESS - I I1Tt7.. L 1u
tion 7044, Buslnem and Professlons Code.)
EXIST.- DEC
CONSTRUCTION LENDING AGBJCY R5aLJI YARD HWY FRCYNi 7O.`r'
I hereby affirm that there Is a construction lending agency for FRONT CAME .01)
the performance of the work for which this permit Is hued RL -
(Sec 3097, Clv. C.): SIDE
-P.L -
Lenders Name 30HU1 9/ 6/WI
R.C. Fee permit Fee 5 7.3 8 LD"Ref. 2762 JL 1 AM 9'133
Lenders Address
o I certify that I have read this application and state that the [nuance 13•00 [DMA O/C/
above Information Is correct. I agree to comply with all County Investtpaflon Fee
ordinances and State lawsrel ng to building construction, Fee .3$ LDMA Perm.
< an r thorize r. Ives of this Coun o ant
Y$ n ve- t party for I
r fS 4ffVQfi'FOR DULANATORY LANGkMG1
Slgnattrre of nt or Agent