HomeMy Public PortalAbout9727 RICHMOND WAY_Building__ WORKERS'COMPENSATION DECLARATION
stgeltq affirm that I have certificate of consent to self APPLICATION
P P L I C®T I FORBUILDING
U I L®I N G PERMIT
insure, or a certificate of Workers'Compensation Insurance, �'°'�►
•;,a 6;rtified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑olicyNW2801�Company_Fi reManc Filnd_ BUILDING .
Certified copy is hereby furnished. OR APPLICANT TO FILL IN ADDRESS IC ILID
�J Certified copy is filed with th unty builds inspec- FOFL:OT
4� tion department. 7 l UrU �, Lot 22 Plan D, Eley B
VJ
Date O plicant r/ Temple Cit zip 91780 LOCALITY SW corner Golden West &
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. .NEAREST
COMPENSATION INSURANCE rre" NOW ON LOT 0 CROSS ST. Lotter Azusa
(This section need not be completed if the permit is for oneASSESSOR
PARCEL
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE
OWNER Owen Construction No. 575-0503 `USE ZONE MAP
I certify that in the performance of the work for which this ! NO. y
permit is issued, I shall not employ any person in any mannerSPECIAL 05
so as to become subject to the Workers'Compensation Laws. ADDRESS 4275 Baldwin Ave CONDITIONS U
CITY El Mogate ZIP 91731 @S
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT G OUP TYPE FIRE PR CE SED BY
ENGINEER Courtne N0331-306 CONST. ZONE
Exemption, you should become subject to the Workers' X
Compensatin provisions of the Labor Code, you must forth- ADDRESS 529 S Hollenbeck Jam'®U
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. NDO.
deemed revoked. CONTRACTOR Owen Construction NO,575-0503 L g
00
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
7
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS No444758 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 VALIDATION
FT'
HECK
License Nu er Lic.Class R
SIZE 2329 STORIES 2 FAMILOIES 1 CONE
(� VALUATION
DESCRIPTION OF WORK /� !� �4 4 9.2 A
Contract Date
��. �o NEW $ V� �����`�
ADD
I am exempt under Sec. Home witil attached arae ❑001. a a a a
ALTER ❑'
B.BP.C. for this reason REPAIR ❑i $ 1 - 4 8 0 6 2
USE OF
Date: DEMOL
EXISTING BLDG. ❑ i
APPLICANT TEL. FINAL /7 4 L C,6 Li
Signature OWNER-BUILDER DECLARATION PRINT (ven Construction NO575-0503 DATE '%�`
I hereby affirm that I am exempt from the Contractor's License d 4'2 1 — b
Law for the following reason (Section 7031.5, Business and ADDRESS FI a 01
WIVProfessions Code): PRE ENT
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and LOCALITY �t
the structure is not intended or offered for sale(Section t
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 SETT BACK YARD HWY ED TOTAPRROPAINEFROM WIDTH a 5 7 7,0 A
I hereby affirm that there is a construction lending agency for FRONT # o a o 0 0 1
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
1/1-1k
/ P.L. I a 81 8 2 5
P Lender's Name 11� -75 LDMA Ref. # o o £j 1
e$ Permit Fee i
- Lender's Address P.C.Fe
-� 10.2 f --:: 5
I certify that I have read this application and state that the b Issuance Fee • ✓` LDMA P/C#
abo inf ation is correct. I agree to comply with all County Investigation Fee
ord nc s nd State laws relating to building construction, Total Fee A LDMA Perm. #
and ler by uth ize representatives of this County to enter
i< up. th a ve- entioned property for inspection purposes.
Cts.!, ¢ SEE REVERSE FOR EXPLANATORY LANGUAGE
@�
Signa re of App scant or Agent Date