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HomeMy Public PortalAbout9726 RICHMOND WAY_Building__ / i" ,WORKERS'COMPENSATION DECLARATION `i ! i hergby affirm that I have r certificate of consent to self APPLICATION WING p E RM I T insure, ora certificate of Workers'Compensation Insurance, .;l certified copy thereof(Sec. 3800,Lob. C.) COUNTY OF LOS ANGELES I' i..l BUILDING AND SAFETY Policy No ompony Vi ram,na Ftp F1Certifiedcopy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ADDRESS / (CN1h'I DAllJ ADDRESS Z ® Certified copy is filed with f e county building inspec- J� NGINEER UILDING ��/ I� '�� A tion department. DDRESS �O `; Plan D Elev A reverse Datt�G Applicant R.t w ITY r zIP 780 LOCALITY SW corner Golden West CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE IZE OF LOT Irril NOW ON LOT .CROSS'ST. Loader Azusa (ThiASSESSOR s section need not be completed if the permit is for.one RACT 43199 BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars($100)or less.) TEL. `:''USE SONE' MAP I certify that in the performance of the work for which this WNER Owen Construction NO.575-0503 /K) NO. } permit is issued, I shall not employ any person in any manner DDRESS 4275 Baldwin Ave. SPECIAL 13 so as to become subject to the Workers Compensation Laws. CONDITIONS 40 ITY El Monte zip 91731 i 9 Date Applicant RCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this Certificate of a NO. 331-3060 DISTRICT GROUP TYPE FIRE PRO SSED BY Exemption, you should become subject to the Workers' CONST`./ ZONE Compensation provisions of the Labor Code, you must forth- ppRE� 529 S Hollenbeck `� °` I� with comply with such provisions or this permit shall be TEL STATISTICAL CLASSI KATION APT. DO. � deemed revoked. CONTRACTOR Owen Construction NO. 575-0503 g LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. Q"/ 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. 4'• SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASSB BK PG VALID4T.1l ;1 SQ.FT. NO.OF NO.OF CHECK Licensetber,�' Lic.Class B SIZE 2329 STORIES 2 FAMILIES 1 ONEo 0 0 VALUATIQIG. DESCRIPTION OF WORK T e Famil NE`^' ® $ I ° 8 5ContracDate ❑ ADD ❑ I am exempt under Sec. a with attached arae _ ALTER ❑ ° ° 1i-••,0,6 r. B.BP.C. for this reason [E] $ r. USE OF ❑ 04,C 1 -t C Date: EXISTING BLDG. DEMOL El APPLICANT TEL. ;, 'FINAL Signature OWNER-BUILDER DECLARATION (PRINT) Oven Constructs No, 57 0503 DATE 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS F Professions Code): PRESENT _y, EI1, 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 SEMACK YARD HWY TOTAPROP.LNE—CK WIDTH 5 7 7.4 A I hereby affirm that there is a construction lending agency for FRONT o o a o a 1 the performance of the work for which this permit is issued �: P.L. (Sec. 3097, Civ. C.). SIDE n P.L. LPerm. , ( ° 8 1 8,c 5 Q Lender's Name �" A — o a 3 8 5 6 L� P.C.Fee$ Permit Fee �s 75 ® `� Lender's Address /� xI certify that I have read this application and state that the - r `L Issuance Fee 0 �� I �.G 8—�' 6 above information is correct. I agree to comply with all County Investigation Fee G a° R..n a d State laws relafin.g to building construction, Total Fee a , y uthorize representatives of this County to entermm= ab ve ment�property for inspection purposes.�d SEE REVERSE FOR EXPLANATORY LANGUAGEo ©.g 2r e of Applicant or Agent ' Date