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HomeMy Public PortalAbout8829 ELM AVE_Building__ WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a.certificate of consent to self D D ' D O D unsure, or a certificate of.Workers'Compenstion Insurance, or. - ./p P d�CLQ 0 O�] 0�3 .Q M D d a certified copy thereof.(Sec. 3800, Lab. C.) Policy"N 8-3-44676 Company 'Fremont.Indemnity COUNTY OF LOS ANGELES BUILDIi�IG AND SAFETY F-1 BUILDING . Certified copy is hereby furnished.. _ FOR APPLICANT TO FILL IN ADDRESS �+ - ® Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS- 8829 Elm LOCALITY NEAREST Date'-.4125/83 Applicant Virgin Roof Co. CITY.Te le Cit -ZIP CROSS ST. CERTIFICATE'OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR ,COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT - MAP BOOK PAGE PARCEL USE ZONE MAP (This section need not be completed if the permit is for one v.(r7a hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. TEL. SPECIAL I certify that in tl'a performance*of the work for which.this OWNER NO. CONDITIONS permit is issued, I shall not employ any person in any manner D STRICT, GROUP TYPE FIRE PRO ESSED BY � ADDRESS1044 JIM so as to become subject.to the Workers'Compensation Laws. CONS ` E CITY Arcadia ZIP Date Appi2anT STATISTICAL CLASSIFICATION CONDO. V , NOTICE TO APPLICANT: If-, after making this Certificate of ARCHITECT OR - TEL. LU Exemption,' you should become .subject to the, Workers' ENGINEER NO. CLASS NO. DWELL. UNITS N Compensation provisions of The Labor Code, you must forth- ADDRESS SEWER MAP' Z with comply-.with' such provisions or this permit shall be . deemed revoked. EL BK: PG VALIDATION CONTRACTOR Virgin Roof Co.CO NC287�0507 ' LICENSED CONTRACTORS DECLARATION LIC. _ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 600 S San Gabriel NO..160651 ALUATION (commencing with Section-7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS .C39 $- 1700000 SQ. FT. NO. OF NO. OF. CHECK License Number 160650 Lic.Class C39 SIZE STORIES FAMILIES ONE NEW ❑ $ Contractor Virgin Roof GO,Date 4/25/83 DESCRIPTION OF WORKRp—rnof With " ; I am exempt from the licensing requirements as I am a 28#y 111# and 72# ADD licensed architect or a registered professional `engineer ALTER FINAL acting in my professional capacity (Section 7051, f� REPAIR -® DATE Business and Professions Code). USE OF O FINAL PADDRE BLDG. DEMOL B Lic.or Reg.No Date NT TEL Y OWNER-BUILDER DECLARATION r in Roof CO -N6287-0507 r I hereby affirm that I am exempt from the Contractor's License 6OO S San Gabriel B1Vdp San Gabr v ��Law for the following reason (Section 7031.5„Business and Professions Code): PRESENT ' r ..' .BUILDING ft - I, as owner of the property, or my employees with ADDRESS ��;. wages as their sole compensation, will do the work and the structure is not intended or offered for sale(Section LOCALITY 2'0 0.4 9'V 8 8 7044, Business and Professions Code). MOVING TEL. //'' r1 pr, _. , - CONTRACTOR. NO. .,. P,o 0,�1. 7, S.c,, � -I, as owner of the property, am.exclusively.contracting with licensed contractors to construct the project (Seo- ADDRESS O 5,0 6—'8 3 .tion 7044, Business and Professions Code). _ REQUIRED TOTAL SETBACK-FROM' EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm 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 P.I, Lender's Name mP.C. Fee$ Permit Fee V 2 Lender's Address 0 W I'certify that I have read this application and 'state that the Issuance Fee: above information is correct. I agree to comply with all County Investigation Fee . lo ordinances and State laws relating to building construction, Total Fee 6 - an heieby authorize representatives.of this County to enter ° aup the above'mentioned property or inspection purpdses. a SEE REVERSE FOR EXPLANATORY LANGUAGE ^ �nowre p c A or gent Dote - ©s