HomeMy Public PortalAbout9722 RICHMOND WAY_Building__ • f
WORKERS'COMPENSATION DECLARATION
e o affirm that I have r certificate of consent to self ®®L I CAT 1®IV F O RN ��I L®I I� PERMIT
�
� Insure, or a certificate of Workers'Compensation Insurance,
or a certified copy there307
f�Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy f bf)t�✓r CCoo`mpany Fi remang Ptjnd /
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING h , 7 (C jt7n2UA1t7
ADDRESS +
Certified copy is filed with the county building inspec- BUILDING /Zi(�► `
tion departure ; ADDRESS ► �Gie. t� Ud �', Ijot 1-3 Plan E Elev B
Datef , `3Applicant CITY Te O e Cit zlP 91780 LOCALITY SW corner Golden West &
CERTIFICATE OF EXEMPTI FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT Irreq NOW ON LOT Y CROSS ST.Lower MUSA
(This section need not be completed if the permit is for oneASSESSOR
TRACT 43189 BLOCK LOT NO. MAP BOOKPAGE PARCEL
hundred dollars($100)or less.)
'. OWNER � � N0575-0503USE ZONE MAP t Z
I certify that in the performance of the work for which this n NO. >_
permit ADDRESS 4275 Baldwin is issued, I shall not employ any person in any manner in Ave '/- 1 SPECIAL IL
so as to become subject to the Workers'Compensation Laws. 771��� CONDITIONS �O
CITY El Monte zip 91731 09
Date Applicant DISTRICT GROUP TYPE FIRE PROCESSED BY 0
NOTICE TO APPLICANT: If, after makingthis Certificate of ARCHITECT OR TEL.
ENGINEER CourtneyNO. 331-3060 CONST. ZONE
Exemption, you should become subject to the Workers' /l(( ��3 / 1 A/ Am
Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S Hollenbeck 5'V(J v y
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. LNDO. 2E
deemed revoked. CONTRACTOR Wan Construction No. 575-0503
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. iJ DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 „ADDRESS NO. 44475FI SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in full force and effect. CITY CLASS B BK PG VAUDATJWi. A
SQ.FT. NO.OF NO.OF CHECK - -
License Nu b r Lic.Class R SIZE 23-52 STORIES 2 FAMILIES 1 ONE f% ° ' °
p� VALUATION
Contractor Date ' .-U(� DESCRIPTION OF WORK New Single F amij NEW $ /� 0 �,�� o o
❑ I am exempt under Sec. Home with attaehe(a ara' a ADD ❑` (1
ALTER ❑ .
B.BP.C. for this reason REPAIR ❑ $
USE OF ❑
Date: EXISTING BLDG. DEMOL
Signature APPLICANT TEL, FINALI
OWNER-BUILDER DECLARATION PRINT) Owen ConstructiJ11 NO. X75-0503 DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS FI
Law for the following reason (Section 7031.5, Business and
Professions Code): PRE ENT B
❑ 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
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). `5 7 7 AREQUIRED Y TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
YARD HW
I hereby affirm that there is a construction lending agency for FRONT o c
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). l n SIDE ) ° t•2 2 7 5
N! I"` !
P.L.
o ..
e Lender's Name LDMA Ref. tT
iI P.C. Fee$ Permit Fee • 1J--
aboveLender's Address Icertify tt I have read this application and state that the 3129 Issuance Fee lQ LDMA P/C#
in oration is correct. I agree to comply with all County Investigation Fee q
3 ordinan an a laws relating to building construction, Total Fee .-C ao 7 LDMA Perm. #
and h e y of, oil
ze representatives of this County to enter
� upo a ve en• ned property for inspection purposes.
i l Q SEE REVERSE FOR EXPLANATORY LANGUAGE
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\ P I
Sig re of Applicant or Agent Date