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Home My Public Portal About9711 RICHMOND WAY_Building__ WORKERS'COMPENSATION DECLARATION ,1 hereby affirm that I have a Certificate of consent to self insure'P�or a cortif icate of Workers'Compensation Insurance, a* APPLICATION FVR BUILDING PERMIT 0 5 ortifiecrcopy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NW2BDJAa9BZComPcmy Fir _mans Fund Certified copy is hereby furnished. FOR APPLICANTBUILDINGW Certified copy is filed with the county building inspec- BUILDING M A" OTO FILL IN ADDRESS It-7 4*7rC Y43,1 S, tion department. ADDRESS_A ACHWIU-0kAla�, Lot 18 Plan Jr Eley B DoteLb LApplicant 1 CITY ITY T �gMgle City_- zip 91780 ',.LOCALITY SK corner Golden West & CERTIFICATE OF EXEMPTIObIROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT Irreq NOW ON LOT 0 CROSS ST.Lower Azusa (This section need not be completed if the permit Is for one ASSESSOR hundred dollars($100)or less.) TRACT 43189 BLOCK LOT NO, _T MAP BOOK PAGE PARCEL TEL. USE ZONE MAP I certify that in the performance of the work for which this OWNER Owen COnstructlon No. -975-0503 -2-6 permit is Issued, I shall not employ any person in any manner INO 7� ADDRESS 4275 CONDITIONS so as to become subject to the Workers Compensation Laws. Baldwin Ave ONOIT ONS 0 DateApplicant -CITY El Monte zip 91731 — NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR DISTRICT GROUP TYPE FIRE PRO Exemption, you should become subject to the Workers' ENGINEER Courtney NO. 331-3060 ED BY Compensation provisions of the Labor Code, you must forth- 5/09 CONST. ZONE ADDRESS 529 S Holl-enbeck 5 with comply with such provisions or this permit shall be t V I — 1 7 deemed revoked. TEL. STATISTICAL CLASSIFICATION U1 LICENSED CONTRACTORS DECLARATION CONTRACTOR Owen Construction No. 75-0503 L 1 APT. C DO. I hereby affirm that I am licensed under provisions of Chapter 9 UC. 4758 CLASS NO.-_ (0 0– DWELL. UNITS (commencing with Section 7000)of Division 3 of the Business and ADDRESS N44 LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS SK. PG. VALIDATION NO.SO.FT. O-OF NO.OF CHECK -- License blumber 44479 8—Lic.Class____J3_ S17r _2536 STORIES 2 FAMILIES I ONE ,44a Contra karlV_�_GLT-t– DJeLA: DESCRIPTION OF WORK NeW ,Sin ile-FalTiily NEW VALUATION # ADD Lx ;,L $ 41,0,01 z I am exempt under Sec. -lictines with attached-ciarage — ALTER E 7 1, IC 2 B.&P.C.for this reason REPAIR r $ USE OF Date: EXISTING BLDG. DEMOL 0 7 1, Signature APPLICANT TEL' 0 2 OWNER-BUILDER DECLARATION (PRI T) Owen Construction No. 575-0503 FINAL I hereby affirm that I am exempt from the Contractor's License DATE Low for the following reason (Section 7031.5, Business and ,ADDRESS FIN Professions Code): PRE NENI BUILDING El 1, 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 TEL. 1,as owner of the property,am exclusively contracting CONTRACTOR NO, with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). ADDRESS i w REQUIREDwe" CONSTRUCTION LENDING AGENCY � YARD HWY TOTAL SET CKFROM Pilo. I hereby affirm that there is a construction lending agency for SET BACK PROP.LINE WIDTH P5 7 7.4 A the performance of the work for which this permit is issued P.L. 0 0 0 0 0 (Sec. 3097, Civ. C.). SIDE P.L. I - 8. 875 , Lender's Name /V/A 1, - - 858751 P.C. Fee$ Ref. Lender's Address FRONT 1021- Permit Fee 7s7- 12� * D A Ref.49 L M I certify th I have read this application and state that the 1 Q23-F6 CA --- Issuance Fee VLDMA P/C# above info atio orrect. I agree to comply with all County Investigation—Fee ordinanc n to laws relating to building construction, and here thor* 0 representatives of this County to enter Total Fee LDMA Perm.# upon the ve- ritioned property for inspection purposes. _L__ SEE REVERSE FOR EXPLANATORY LANGUAGE mature/ Appiicani or Agent Dow