HomeMy Public PortalAbout9719 RICHMOND WAY_Building__ W.
t WORKERS'COMPENSATION DECLARATION
hF. s afilr?R that I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T
insurur,E. dr a certificate of Workers'Compensation Insurance,
o,•a certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy MsTfla 4agBZCompany Pi reManc Rtmr7
❑ Certified copy is hereby furnished. R APPLICANT TO FILL IN BUILDING � '
ADDRESS
Certified copy is filed with t county build' inspec- BUILDING VA
tion departm nt. ADDRESS IdN i odb h/ Lot 20 Plan E, Eley A Reverse
Date�� Applicant �1 CITY Temple City zip 91780 LOCALITY SW corner Golden West &
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS.OT NEAREST
SIZE OF LOT Irre
COMPENSATION INSURANCE NOW ON YJ CROSS ST.LO-rier 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.OWNER Owen Construction NO. 575-0503 USE ZONE MAP
9- 1 I certify that in the performance of the work for which this SPECIAL 911.aldtrn Ave.
permit is issued, I shall not employ any person in any manner ADDRESS 4275 Bi
so as to become subject to the Workers'Compensation Laws. CONDITIONS 0O
CITY El MOnte zip 91731 29
Date Applicant ARCHITECT OR TEL. G
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Courtne No331-3060 DISTRICT GROUP TYPE FIRE PROC SED BY
Exemption, you should become subject to the Workers' /� CONST. ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S Hollenbeck 5r� U R. IIL
L
with comply with such provisions or this permit shall be rA
TEL. STATISTICAL CLASSIFICATION APT
deemed revoked. CONTRACTOR 074an Construction NO. 5750503 ��
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.—S.—DWELL. UNITS_L.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 444758
(commencing with Section 7000)of Division 3 of the Business and LIC, SEWER MAP t r
Professions Code, and my license is in full force and effect. CITY CLASS B BK PGVALIDATION
SQ. FT., NO.OF NO.OF CHECK
License N ber 44758 Lic.Class B SIZE STORIES 2 FAMILIES 1 ONE °
VALUATION
Contracto Date DESCRIPTION OF WORK New Single FamilyNEW ® : n ,7 J
ADD ❑ V
71
❑ I am exempt under Sec. Home Wlth attached garage ALTER Eloil,
B.BP.C. for this reason REPAIR ❑ $
Date:
USE OF ❑
DEMOL
EXISTING BLDG.
APPLICANT TEL.
Signature (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 FI
Professions Code): PRESENT B
El1,
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.
❑ 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).
REQUIRED YARD HWY TOTAL SETBACK FROM' X 5 7 7 �,
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT # 0 0 0 0 0
the performance of the work for which this permit is issued P.L.
(Sec. 3097,Civ. C.). SIDE
P.L.
Lender's Name ° °
Q LDMA Ref. #
P.C. Fee$ / o t Permit Fee Z'Z� + C _ c,
Lender's Address '
1 certify that I have read this application and state that the Issuance Fee �• -� LDMA P/C#
¢ above f'formatio correct. I agree to comply with all County Investigation Fee
ordv es a S to laws relating to building construction, Total Fee 57 LDMA Perm. #
u and htlebyQuthze representatives of this County to enter
upon ant ned property for inspection purpose
o SEE REVERSE FOR EXPLANATORY LANGUAGE
LO'n
i natur Applicant or Agent Date t