HomeMy Public PortalAbout9715 RICHMOND WAY_Building__ -WORKERS'COMPENSATION DECLARATION
thereby a certificate
that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.)
PolicyNoTnP,� i r mans Fund COUNTY OF LOS ANGELES BUILDING AND SAFETY
Rn14398 Company_F
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING C ! ' w�,0
ADDRESS J
1-1 Certified copy is filed with th county building inspec- BUILDING
uU
tion department. ADDRESS q A&M-woo /JU Lot 19 Plan Hr Elev B reverse
Datr , J' Applicant CITY Temple Cit- ZIP 91780 LOCALITYSW corner Golden West &
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT Irre NOW ON LOT 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. MAP BOOK PAGE PARCEL
TEL. USE ZONE MAP
I certify that in the performance of the work for which this OWNER NO. — NO,
permit is issued, I shall not employ any person in any manner i SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS 4275 Baldwin Ave CONDITIONS 0
Date Applicant CITY El Monte ZIP 91731 129
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE ?PARSED BY
Exemption, you should become subject to the Workers' ENGINEER Courtney N0.331- CONST.'/ ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S Hollenbeck s for R-3 Pf �
with comply with such provisions or this permit shall be vs
deemed revoked. TEL STATISTICAL CLASSIFICATION APT.CONTRACTOR Owen ConstructionNo.575-0503 �qLICENSED CONTRACTORS DECLARATION LIC. CLASS NO. Vy DWELL. UNITS+ fNDO.Q 7 r,
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS No.444758 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC. 0 0 0 0
Professions Code, and my license is in full force and effect. CITY CLASS B BK PG VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License Nu ber 444758 Lic.Class R SIZE STORIES FAMILIES I ONE 1 ° 6 1 S 9 3
VALUATION _
Contractor , DOte DESCRIPTION OF WORK 1VetT e Family NEW $ Q- 9_3640 ° ° 6 I 5 `)
ADD U
❑ I am exempt under Sec. Home With attached ara re ALTER ❑ 0111. U C.L - — . 6
B.&P.C. for this reason REPAIR E] $
Date: USE OF OL
EXISTING BLDG. DEM ❑
Signature APPLICANTTEL. FINAL
OWNER-BUILDER DECLARATION
(PRINT)Owen Construction No.575-0503 DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FIN
Professions 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 ' r
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- ADDRESS
tion 7044, Business and Professions Code).
REQCONSTRUCTION LENDING AGENCY SETT BACK YARD HWY IRED TOTAPREOTPAINEFR M WIDTH Jr 7 7,3 A
I hereby affirm that there is a construction lending agency for FRONT �t o 0 0 0 0
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE ( o 7 3 ra C 0
'a P.L.
Lender's Name U LDMA Ref. # ° ° 5. p
P.C. Fee$ `� �+ `v� Permit Fee r C$"$6
Lender's Address '
I certify atkhaveead this application and state that the Issuance Feeabove' rmorrect. I agree to comply with all County Investigation Fee ordin s laws relating to building construction, Total Fee v LDMA Perm. #u and e y representatives of this County to enter
upo aboned property for inspection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ppicant or Agent Date