HomeMy Public PortalAbout9723 RICHMOND WAY_Building__ ."%W 4VORKERS'COMPENSATION DECLARATION
harm• a ter that I have certificate of consent to self APPLI "NCA T ®� U I L®I N G PERMIT 1.Vla c, ora certificate of Workers'Compensation Insurance,
a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nb1P807 4xgB2 Company Pi rpTnnna Funr7 ,• _
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING 1(i ?�12(ji11
LSU Certified copy is filed with the county building inspec- rTRACT43189
�J Tion department. 3 H-M AY(� . Lot 21 Plan D, Elev A Reverse
Date a ' pplicant Temole C ZIP LOCALITY S corner Golden
CERTIFI ATE OF EXEMPTION 15MWORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE 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.) 189 BLOCK LOT NO. MAP BOOKPAGE PARCEL
TEL. USE ONJ I certify that in the performance of the work for which this a NO. — NO. >_
permit is issued, I shall not employ any person in any manner SPECIALso as to become subject to the Workers'Compensation Laws. 275 Baldwin Ave. CONDITIONS 0
CITY El Monte ZIP 91731 Rd
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Courtney NO. 331-3060 �v CONST./ Z E
Exemption, you should become subject to the Workers' b 1V/ %y
Compensation provisions of the Labor Code, you must forth- gDDRESS 529 S H011enbeC}c r �
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT.
deemed revoked. CONTRACTOR Oven Construction NO. 575-0503
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 60 DWELL. UNITS
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
Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License N er Lic.Class B SIZE 2329 STORIES 2 FAMILIES ONE
i NEW VALUATION 7, +r 4 4 9 j ;3
Contracto Date ; DESCRIPTION OF WORK C 0 $ 0/ O��� o Q A 5 F I
ADD ❑I, .:.. !(/ w to o yj >'
I am exempt under Sec. Home with atta ed ALTER 00—
B.BP.C. for this reason REPAIR ❑ $
USE OF ❑
Date: EXISTING BLDG. DEMOL
Signature APPLICANT TEL. r FINAL
g 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 k By
❑ a 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 t
7044, Business and Professions Code). MOVING TEL.
I, as owner of the property,am exclusively contracting CONTRACTOR NO. t4
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code). ADDRESS
REQUIRED YARD HWY TOTAL.SETBACK FROW 5 7 �, 1 p
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
1 hereby affirm that there is a construction lending agency for A FRONT # 0 0 0 0 a 1
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
r LInvestigation
I a 81 &25
i Lender's Name / A y o o
�� LDMA Ref. # 1 G
r�j 0 Permit Fee Q
Lender's Address I a L€ 6
I certify that I have read this application and state that the Issuance Fee U �� LDMA P/C#
iabove information is correct. I agree to comply with all County Fee G
or antes a tate laws relating to building construction, Total Fee O s LDMA Perm. #
a d ereby aut orize representatives of this County to enter
U
the ov me oned property for inspection purpo s.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signal of Applicant or Agent Dat