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HomeMy Public PortalAbout9801 RICHMOND WAY_Building__ WORKERS' COMPENSATION DECLARATION F.I:nsure, hereb affirm that I have a certificate of consent to selfy APPLI ATION R BUILDING PERMIT or a certificate of Workers' Compensation Insurance,a certified,fgp�,here f Sec. 3800, Lab. C.) //fi�n�...V.��SS // COUNTY OF LOS ANGELES BUILDING AND SAFETY PoliEy`No. Compan S r,&S BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- fADDRESS LDING C- , tion department.Dote 4-23-89 Appl nt �--Y ,�- Y Temple City ZIP 917 8 0 LOCALITY C' I ' NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION OM W K SIZE OF LOT 87000 NOW ON LOT CROSS 57. COMPENSATION Ib URANC ASSESSOR (This section need not be completed if the permit is for one TRACT 43136 BLOCK LOT IN MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL. OWNER We St CO Land Inc . No 286-3636 USE ZONE NO. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner ADDRESS 14 2 5 Melanie lane SPECIAL } CL so , r so as to become subject to the Workers'Compensation Laws. O CIN A r c a d i s zip 91006 ?,�07 , r : q Date Applicant ARCHITECT OR TEL. 1 �'-i� Same DISTRICT GROUP TYPE FIR PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. W O Exemption, you should become subject to the Workers' .i CONST. / ZO E U Compensation provisions of the Labor Code, SP � �A�;( a p p you must forth- ADDRESS �� with comply with such provisions or this permit shall be Same TEL. STATISTICAL CLASSIFICATIONy�PT. JCONDO. h deemed revoked. CONTRACTOR NO. �: ,,�r +: iyMz LICENSED CONTRACTORS DECLARATION LIC. 265864 CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. pp�� C and Professions Code,and my license is in full force and effect. CITY CLASS TOT 11315.9C' 11315.;�I-' SO. FT. NO. OF NO. OF CHECK BK. PG. �4tic. Class 2050 2 �: — License Number SIZE STORIES NO ONE ��C fir/ 1i� IN VALUATION Conirocto � -' Date_ DESCRIPTION OF WORK Single Family NEY� $� {•�UE ❑I am exempt under Se/ Residential attached 2car ADD ❑ B.BP.C. for this reason Garage ALTER ❑ , 0000-0001 S/ I/y. USE OF REPAIR ❑ $ /a2©/ 000 4W3 1 rM 94-136 Date: EXISTING BLDG. Single f ami l y R e s i DEMOL ❑ Signature APPLICANT OWNER-BUILDER DECLARATION (PRINT) G e O r e W i e and No. 286-3636 FINAL I hereby affirm that I am exempt from the Contractor's License DATE Law for the following reason (Section 7031.5, Business and ADDRESSMelanie Lane Arcadia FINAL Professions Code): PRESENT By v BUILDING n ❑ I, as owner of the property, or my employees with ADDRESS �V wages as their sole compensation,wiII 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 REQUIRED YARD HWY TOTAL ETBPROP. LINE FROM WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE Lender's Name B B H Mortgage P.L. 8383 Wilshire Beverly hil C. Fee$ Permit Fee99Y, 75 LDMA Ref. # Lender's Address I certify that I have read this application and state that the Issuance Fee /0 ISO LDMA P/C# , above information is correct. I agree to comply with all County Investigation e ordinances and State laws relating to building construction, 7—�(�(L�a �—� Total Fee 7 p LDMA Perm. # and hereby authorize representatives of this County to enter upon the above-mentio ed pr pe ty for in ection pu oses r c'- " �� SEE REVERSE FOR EXPLANATORY LANGUAGE Sign re of Plicaor nt Date