HomeMy Public PortalAbout6236 ENCINITA AVE_Building__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of,consent to self & PPLOCAMNf FOR BURDONG. PC�03M07
insure, or a certificate of Workers' Compensation Insurance,
-a
or a certified copy thereof (Sec. 3800,'Lob. C.) i COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. 1046140 Company State Fund /
❑ Certified copy is hereby furnished. FOR APPLICANT TOTILL IN' ADDRESS (O
❑7L Certified copy.is filed with the county building inspec- BUDDING' 6236 Encinitas T.Cy. 91780 - -
tion department.
Date 11-1-89. .Applicant Randol Roofing CITY ' T.0 ZIP- 1780 LOCALITY
NO. OF BLDGS. NEAREST_
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. IF
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK - LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100)or Tess.) TEL,
OWNER - NO, — USE ONE MAP
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any manner ADDRESS 6236 EnC int to Ave SPECIAL d
CONDITIONS
•'so as to become subject to the Workers'Compensation laws. - O
3- 9 Randol Roofing CITY T..0 ZIP 91780 u
Dote �3f8lh�3f��R Applicant - ARCHITECT OR - TEL. DISTRICT GROUP TYPE FIRE ROCESSED BY Q
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER . NO. CON SNE F—
Exemption, you should become' subject to the Workers' _ < ! w
Compensation provisions of the Labor Code, you must forth- ADDRESS 6,09
aJ
with comply,with such provisions or this permit shall be TEL STATISTICAL CLAS$iLIC TION APT. CONDO. Z
deemed revoked. CONTRACTOR Randol Roof in Na 288-4040 a,(/
LICENSED CONTRACTORS DECLARATION LIC CLASS NO.�DWELL. UNITS_
ADDRESS 529 E. Valley B1vdNO451937
I hereby affirm that I am licensed under provisions of Chapter 9 - - SEWER MAP
(commencing with Section 7000)of Division 3 of the BusinessaTv- San Gabriel, Ca. LICP.$S C-39
.and Professions Code,and my license is in full force and effect. BK PG, VALIDATION
SQ. FT. - NO. OF ' NO. OF CHECK"
License Number. 451937 Lic Class C-39 SIZE I STORIES FAMILIES ONE
❑ VALUATION
Contractor .Randol ' Roofingate 1-31-90 DESCRIPTION OF WORK — NEW
❑I am exempt under sea. garage with 11220 fiberglas shiiT 22Ds LJ $2,000.00 ACCT.gD3307 49.1.
lass A. Roof,. ALTER El 3307
IT�flc•
B.BP.C. for this reason - $ S%
USE OF REPAIR . (LI IAL
Date: EXISTING BLDG. SFD - DEMOL _
Signature APPLICANTTEL. C.H.PC K- 49°L'3
OWNER-BUILDER DECLARATION
(PRINT) Randol Roofing NO 288-4040 FINAL. _
I hereby affirm that I am exempt from the Contractors License 529 .E. Valley Blvd., S.C.-91776 DATE GHAN(]t .00
Law for the following reason (Section 7031.5,Business and ADDRESS FIN
j
Professions Code): PRESENT. _ By � 7
I rll.Ill—)fLll}1 .-/17i_•9
BUILDING
❑ I, as owner of the property, or my employees with ADDRESS - 1_S c
wages as their sole compensation, will do the work and — - D 19 1 AM 9 i L!
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, Bsiness 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.L. -
Lender's Name
m ~ 839.38' LDMA Ref. k
P.C. Fee$ Permit FeeD
Lender's Address
a I certify that have read this application and stale that the Issuance F 10.50
50
tLDMA P/C#
8 _ above information is correct. I agree to comply with all County Investigation Fee $49.88: •�
R ordinances and State laws relating to building construction, T al Fee LDMA Perm. If
and ayth9rize re sent tives of this County to enter
up t bp4�fnenii - pr ert- or inspectiq put
-
Oc% SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent We. -