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HomeMy Public PortalAbout9718 RICHMOND WAY_Building__ .a WORKERS'COMPENSATION DECLARATION Hereby or affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT insute, eicertificate of Workers'Compensation Insurance, or certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑olicyNo` 43 -^.Company Flyomanv Fmt d BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ® Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS �' rYl d to Lot 14 Plan D, Elav B r Date V- Applica CITY a City zip 91780 LOCALITY.SN„Corner Golden West & CERTIFI ATE OF EXEMPTIOYMM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT 01 CROSS ST. Lower Azusa (This section need not be completed if the permit is for one ASSESSOR -hundred dollars($100)or less.) TRACT BLOCK LOT. TEL. MAP BOOK PAGE PARCEL USE ZONE MAP 1 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 SPECIAL r. so as to become subject to the Workers'Compensation Laws. ADDRESS 4275 Baldwin Ave CONDITIONS V Date Applicant CITY El Monte zip 91731 gt NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PR CESSED BY 0 Exemption, you should become subject to the Workers' ENGINEER COurtne' NO.331-3060 �j �( � CONSgT.� ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S Hollenb2C}C r�" R—✓ r 3 with comply with such provisions or this permit shall be g deemed revoked. TEL STATISTICAL CLASSIF ION APT. JCONDO. CONTRACTOR Owen ConstructiOINO*.575-0503 J LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS J I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.444758SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. 441 .5A Professions Code, and my license is in full force and effect. CITY CLASS B BK PG VALIDATION SQ. FT. NO.OF NO.OF CHECK o 0 0 0 2 3 License Nu er 444758 Lic.Class B SIZE STORIES FAMILIES - ONE VALUATION DESCRIPTION OF WORK New Sin 'le Family NEW © 7� I 0 4 8 Q 6 2 Contract /I�- Date �' $ t V r_1I am exempt under Sec. Homes with attached 'ara• a ADD ALTER ❑❑ , o 0 4 8 0.6 2 T B.BP.C. for this reason REPAIR ❑ $ k 2 1 —8 6 USE OF Date: EXISTING BLDG. DEMO' F-1 Signature APPLICANT TEL. PRINT Owen Construction No. 575-0503 FINAL � OWNER-BUILDER DECLARATION 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 B 1 ❑ 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 7044, Business and Professions Code). MOVING TEL. ❑ I,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). CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTAL SETBACK NEER JWIDTA �5 7 7.7 A 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. # o a o o o 1 (Sec. 3097, Civ. C.). / P.L. o 8 1 8,[5 a Lender's Name �� DMA Ref. # 00 �,5P.C. Fee$ Permit Fee Lender's AddressIcertLa have read this application and state that the 6 Issuance Fee �' DMA P/C#abovio correct. I agree to comply with all County Investigation Fee ordinto a laws relating to building construction, Total Fee 1 DMA Perm. # and thor a representatives of this County to enter upo e- nti ed property for inspection purposes. g �� SEE REVERSE FOR EXPLANATORY LANGUAGE O D ignature pplicant or Agent Date