HomeMy Public PortalAbout9528 LEMON AVE_Building__ WORKERS'COMPENSATION DECLARATION -- 850555• BG - ,C. •- 4 i ;
_• brrcertificate self ATIONO
'tion insurance, BLP '
insureoa certifcate a°WarkeSCompensaAPPLIGI T
or'a certified copy thereof (Sec 3800; Lab C ) ,
PoliyNoIV85
c -2251 , p '�` y COUNTY OF LOS ANGELES BUILC1ING:,AND SAFETY"
m any Fremont Indemnit.
❑ Certified copy-is hereby furnished,. BUILDING_ :, • • FOR APPLICANT TO FILL IN ADDRESS
' Certified copy'is filed with the county-building'mspec- BUILDING ;9528 Lemon " t
tion'd'epartm-- }' 1 '4"' • ' ADDRESS I
• •� '� •� '{
Temple Clty' ,
Date.• •10/29/8,57 Applcant• iVirg'in,-Roof Co. CITY ZIP LOCALITY
t CERTIFICATE OF EXEMPTION'FROM'WORKERS' - -" - ---NO OF BLDGS
COMPENSATION!INSURANCE, NEAREST _ -
SIZE OF LOT NOW ON LOT CROSS ST -
• -•,•. T '
JKis't section Aeed;not be completed'if•the i �permit'is for one - - - - ASSESSOR - . - • - '
hundred dollars ($100)!on less ) TRACT BLOCK LOT NO MAP BOOK PAGE I PARCEL<
_ Louise-Te atZ
TEL USE ZONE MAP ''nd �jr�v
i1 OWNER gg NO - (i(/U✓
I certify thaf,m The performance of the work for which this � ' SPOECIAL - - - - - --- • d
C is issued, I sFiall not employ any person in'' n` manner _, -ADDRESS 9532 Lemon - CONDITIONS O
so as•to become sublgct to the'Workers"Compensdtion'Laws U
• •t•, Temple City --_ . , . . .. �-•- --- -J• - .' - ,
CIT.Y.- ZIP,
Date` , '' 'Applicant' _ I O
NOTICE TO APPLICANT "If,--after making this'Certificate of ARCHITECT OR TEL DISTRICT,/ GROUP TYPE, _ FIRE _ PRO SSED BY
ENGINEER NO CONST ZONE
Exem tion; you should become subject, to•+the'Workers' V Q QUJ
Compensate n.provisions,of the Labor•Code, you must forth- ADDRESS
with comply with, suchtprovisions or,this,,permit shall be - - - •--• - - - 'TEL _ STATISTICAL CLASSIFICATION APT NDO Z
deemed revoked' ;-�, , ,I - ;• CONTRACTOR Virgin Roof Co. •NO 287-050 l
LICENSED CONTRACTORS DECLARATION -LIC CLASS NODVVEII' UNITS-
P.0.' Box-J `16-0650
I hereby affirm that I am licensed provisions of Chapter 9- ADDRESS NO _
commenctn wick Section 7000 of Division 3 of the Business and' SEWER MAP
( s )'• - - — San`Gabriel �-Llc . 'C39
' VALIDATION
Professions Code: an'd'my license'e's"in�full force•arid effect CITY _ - CLASS_ BK' PG
' ` ' - • 1".
' t ' I ' _ - SQ FT NO OF NO OF CHECK t
License Number -�y' Lic'Cl'a' ' SIZE STORIES FAMILIES ONE
VALUATION 1 :+. _ -234-I.7_A
• ry,,, DESCRIPTION-OF WORK Re-roof house -with NEW__ ❑
$
2727.00 - $� ooeoo �'
Contractor' -' '• Dote - ,
Cl A composition s'hingl_es 23 s '4 re� -
FT am exempt under Sec ALTER ❑ , ' 1 o - 59,25,'
Flat area with #30 # 15 and #7
B 8P C for this reason REPAIR $ - T -
" Date " ' USEO z squares.dwelling DEMOL ❑ ° a ° 592550 ,
wen
EXISTING BLDG g - -
Sidh5ture - _
APPLICANT'Virgin Roof Co. TEL''287-0507 FINAL (' " 1,0 6_8 5 ;
OWNER-BUILDER DECLARATION PRINT NO OAT ✓ J -- -••
I_hereby offirm.that-I am exempt from the Contractor's License ADDRESS P.O. BOX J SanGabr eel 91778 FIN
Low for the following reason (Section 7031 5, Business and -
PFofessions Code) PRESENT By _.
_ BUILDING
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
•7044, Business•and•Professions-Code)- - - MOVING- - --TEF'
I, as owner of the-property, am exclusively contracting CONTRACTOR NO N - t
with licerised contractors-to construct-the project"(Sec-
ADDRESS"�- t
tion 7044, Business and Professions Code) >
REQUIRED TOTAL SETBACK
" CONSTRUCTION LENDING AGENCY" �` SET BACK YARD" HWY-. PROP LINE WIDTH
hereby affirm that there is a construction lending agency for FRONT t
the performance of the work for{whch this-permit-is issued PL --•• -- - -- - - --__- �...
(Sec 3097, Civ C ) - " SIDE
Lender's No
P L
48.75 LDMA Ref #
PC-Fee•$ - Permit-Fee - _ kLDMA
•iLenders Address
10.50(,,certify that I have read this application andstate that the _ Issuance Fee•- P/C -
< above information is correct I agree to comply with all County Investigation Fee'
Sy ordinanc s and State laws relating to building construction, _ _ _- Total Fee -59.25 _ -LDMA Perm-•#' '• �• - - - -- -
t
v and here y auihonze representatives of his County to enter
- upon th aove-mentioned prop rty for spe tion purp ses
SEE REVERSE FOR EXPLANATORY LANGUAGE ? F
Signa r of-Applicant or Agent-,-•-- ^-• -- ate- - -• ^- -.• •- •• _ _ . . ._.. »-
i