Loading...
HomeMy Public PortalAbout6034 MUSCATEL AVE_Building__ #900363 SB WORKERS'COMPENSATION DECLARATION insurebora certificatffirm e of Workers' Compensation Insuran eI have a certificate of consent to self drt� �'® ® WILDING or a certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. PC99750OCompany Republic Indemnity ElCertified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRIESS 6;9914 © Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 6034 N. Muscatel Date 7-1-91 Applicant Virgin Roof Co. CIN TempleZIP ;:f LOCALITY 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 PARCEL hundred dollars ($100)or less.) TEL. OWNER Virginia McDonald NO. USE ZONE 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 CONDITIONS a- so as to become subject to the Workers'Compensation Laws. O CITY Temple City ZIP 91780 Date Applicant ARCHITECT OR TEL. TYPE NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP CONST. FIRE ONE PROCESSED BY Q Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS �� -' V GfEC•� a- with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR Vir in R O NO• — Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. LIC. SEWER MAP (commencing with Section 7000)of Division 3 of the Business CITY San Gabriel CLASS C39 and Professions Code,and my license is in full force and effect. BK PG VALIDATION SQ. FT. NO. OF NO.OF CHECK License Number 160650 Lic. Class C39 SIZE 21 S STORIES 1 FAMILIES ONE FEW VALUATION Contractor.Virgin Roof CO. Date 6-30-91 DESCRIPTION OF WORK Over existing NEW ❑ $ 2000.00 a ass Fiberglass ADD ❑ El I am exempt under Sec. 1 ClA Fibl ALTER ❑ ; BAP.C. for this reason 'Shingles. 21 s S. REPAIR ❑ $ Date: USE OF EXISTING BLDG. Dwelling DEMOL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) Virgin Roof Co. NO. 287-0507 DATE I hereby affirm that I am exempt from the Contractor's License _ y Law for the following reason (Section 7031.5, Business and ADDRESS P.O. BOX J an Q 'e FINAL Professions Code): PRESENT By BUILDING °a ❑ I, as owner of the property, or my employees with ADDRESS 7 r'il°.�? wages as their sole compensation,will do the work and ` the structure is not intended or offered for sale(Section LOCALITY i> ,��<` `� i T tT��''+L CONTRACTOR NO. TOTIAL 7044, Business and Professions Code.) MOVING TEL. ! t t%\' . 70I ❑ I,as owner of the property,am exclusively contracting � = 37 with licensed contractors to construct the project (Sec- t.l� t_ i tion 7044, Business and Professions Code.) ADDRESS f' 713.1-7 CONSTRUCTION LENDING AGENCY SETA BACK YARD HWY TOTAL SOE PILI K ROM WIDTHE'X . , CHANGE 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. -X71! ! 1 AM �+°nc Lender's Name ''" _ 8 57.37 LDMA Ref.# P.C. Fee$ Permit Fee Lender's Address _ - 1 certify that I have read this application and state that the Issuance Fee 13.00 LDMA P/C# 3 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee LDMA Perm. # and hereby authorize representatives of this County to enter upon theabove- entioned propert for inspection purposes. 111(i11-6-90 SEE REVERSE FOR EXPLANATORY LANGUAGE Si ature of Applicant or Agent Date