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HomeMy Public PortalAbout9714 RICHMOND WAY_Building__ ' s -WORKERS'COMPENSATION DECLARATION +ereE*'y affirm that I have a certificate of consent to self APPLICATION )L I CAT I N F O R �U I L®'� PERMIT E !i T insure, or o certificate of Workers'Compensation Insurance, ®"" or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NWP801�Company Fir2mans Fund ❑ Certified copy is hereby furnishe FOR APPLICANT TO FILL IN BUILDING Otil� ADDRESS (� Certified copy is filed with th cou bu' 'ng Ins p c- BUILDING LJ tion deportment. [" ADDRESSp� Lot 15 Plan H, Elev A Date (;' pplicant ? � C ITY T le Cit zip 91780 SW corner Golden West & LOCALITY CERTIFICATE OF EXEMPTIO OlUI WORKERS' NO.OF BLDGS. NEAREST COMPENSATION i RANCE IZE OF LOT Trre- ' NOW ON LOT ST. Lower Azusa (This section need not be completed if the permit is for one TRACT ASSESSOR hundred dollars($100)or less.) 3 9 BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. USE ZONE MAp -/) I certify that in the performance of the work for which this OWNER Oc>ten Construction NO. 575-0503 NO. eC ?- permit is issued, I shall not employ any person in any manner ADDRESS 4275 Baldwin Ave - SPECIAL so as to become subject to the Workers'Compensation Laws. CONDITIONS Ota Date Applicant CITY El Monte zip 91731 119 NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. , DISTRICT GROUP TYPE FIRE PROCES ED BY CI Exemption, I ENGINEER COurtne NO. 331-3060 u p you should become subject to the Workers' n�( CONST. ZONE � Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S H011enbeck �`+✓I/ -, V with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIF1C/�T10N APT. NDO. deemed revoked. CONTRACTOR Offen C:onstructionTEL-NO. 575-0503 �U LICENSED CONTRACTORS DECLARATION CLASS NO. WELL.UNITS 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS LNOO. 444758 (commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP 4 4 9.8 A Professions Code, and my license is in full force and effect. CITY CLASS B VA`I� D_�A�TI�N2 SQ.FT. NO.OF NO.OF CHECK BK. PG. License Nu r_4. Lic.Class B SIZE 2040 ISTORIES 2 FAMILIES 1 ONE /�� 1^1""ION f o 431.03 %01Contracto Dat (s�`_ DESCRIPTION OF WORK e- Sinal-8- F 'l- NEW $ ""G+ N a e ADD GGt� ✓K9. a a 4 3 1.0 8 5, I am exempt under Set. + -o v a d ALTER LJ B.B,P.C. for this reason REPAIR ❑ $ r1 o4,21 —86 Date: t USE OF DEMOL EXISTING BLDG. SignatureAPPLICANT TEL. FINAL OWNER-BUILDER DECLARATION PRINT Owen Construction NO.575-0503 DATE /17 I hereby affirm that I am exempt from the Contractor's License /, '1— FC. G Law for the following reason (Section 7031.5, Business and ADDRESS RrK Professions Code): PRESENT ❑ BUILDING ' I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and s �'� `5 7 9 0 A the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL, # 0 0 0 0 2 3 ❑ 1,as owner of the property,am exclusively contracting ONTRACTOR NO, with licensed contractors to construct the project (Sec- ADDRESS I o 6 7 8 ni 5 tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FRO T• 0 0 b 7 .O 5 CONSTRUCTION LENDING AGENCY SET BAS YARD HWY PROP UNE WIDTH I hereby affirm that there is a construction lending agency for FRONT 0,28-86 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). � SIDE 2579. 1 A i Lender's Name LDMA Ref.# # 0 0 0 o c ee$ Permit Fee22 R�/� Lender's Address c 1 certify at I have read this application and state that the 3 ©, LpMa P/C# 1073500 Issuance Fee above rm n is correct. I agree to comply with all County ' Fee � p 1 0 0 7; 5 (0 vordin s State laws relating to building construction, Ot7i9 4/. Total Fee 0Q LDMA Perm.# and r a ho ize representatives of this County to enter 3 'a upa e a e- entioned property for inspection purposes. 1 QRS-86 = R REVERSE EXPLANATORY LANGUAGE o iJ Sign re of Applicant or Agent Date Qh i