HomeMy Public PortalAbout5821 MUSCATEL AVE_Building__ Ff IZUJ!04 h.K I
WORKERS'COMPENSATION DECLARATION
hereby Affirm that I have a certificate of consent to self APPLICATION FOR P UILDING PERMIT
insuret ora certificate of Workers' Compensation Insurance, }i
0,I;a Certified copy thereof(Sec. 3800, Lab. C.) ` COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. W2710598Company- Cal. COmD.
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
® Certified copy is filed with the county building inspec- BUILDING ADDRESS
tion department. ADDRESS 5821 Muscatel
7-1-93 Virgin Roof CITY Tem le Cit ZIP 1 =LOCALITY
Date Applicant NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE I PARCEL
hundred dollars ($100)or less.) TEL.
OWNER Mrs. Anna J NO. a USE ZONE MAP
NO.
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS 5821 Muscatel CONDITIONS a
so as to become subject to the Workers'Compensation Laws. n 0
CITY Temple City ZIP 917 U
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. " CONST. ZO E 0
Exemption, you should become subject to the Workers' s A
Compensatioprovisions of the Labor Code, you must forth- h ADDRESS '►, �(/� n,
with comply with such provisions or this permit shall be TEL. `.STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR Virgin ROOF Co. No.287-0 Z
LICENSED CONTRACTORS DECLARATION LIC. . CLASS NO. DWELL. UNITS
ADDRESS P.O. BOX 5010 NC SEWER
'
I hereby affirm that I am licensed under provisions of Chapter 9 v. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effect. CITY San Gabriel CLASS C39 BK VALIDATION
SQ. FT. NO.OF NO. OF CHECK PG.
License Number 160650 Uc. Class C39 SIZE 16 S S STORIES 1 IFAMILIES ONE
NEW 1:1
VALUATION
Contractor Virgin Roof Co. Date 6-30-9 DESCRIPTION OF WORK House Only: Tear $2450.00
❑I am exempt under Sec.
off then a-pply #30 and Class
ADD ❑
ALTER ❑
BAP.C. for this reason A Fiberglass OEPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL 1:1
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT) Virgin Roof C NO — DATE 3 (�
I hereby affirm that I am exempt from the Contractor's License ADDRESS P.0. BOX 5010 San Gab FINAL
Law for the following reason (Section 7031.5, Business and f
Professions Code): PRESENT �: By
El 1,
I, as owner of the property, or my employees with ADDRESS * i / iToAT
wages as their sole compensation,will do the work and ---;307 �c;�e(i?
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL. 1 ITEMS
ti
❑ I,as owner of the property,am exclusively contracting
CONTRACTOR NO.
with licensed contractors to construct the project (Sec- 'I ADDRESS TOTAL 158.07{{
tion 7044, Business and Professions Code.) CHECK 158.0",
EInvestigation
D TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY K YARD HWY PROP. LINE WIDTH ,_H ,�E e411�
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). drten�ryt� ii ��! t,00001—LF091 12/2-3/7.:Lender's NameLDMA Ref. # �2'i�. 1 AM10'-2:4 PermitFee 1Lender's AddressI certify that I have read this application and state that the Issuance Fee 2 LDMA P/C#
above information is correct. I agree to comply with all County Fee
y ordinances and State laws relating to building construction, IT,otal Fee $158.07 LDMA Perm. #
and hereby authorize representatives of this County to enter
upon the ab -me tinned property for inspection purposes.
12-21-92 SEE REVERSE FOR EXPLANATORY LANGUAGE
j ignature of Applicant or Agent Date