HomeMy Public PortalAbout9802 RICHMOND WAY_Building__ WORKERS' COMPENSATION DECLARATION
I hereff irm that'I have a certificate of consent'to
insure, oraa certificate of Workers' Compensation Insuran elf APPLICATION F R BUIDING PERMIT
or a certified copy thereof Sec. 3800, Lab. C.)
.��� � COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polidoe Compan�GV_ r
❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN10 ;.
BUILDING
PY• Y ADDRESS
Eq Certified copy is filed with-the county building'inspec- BUILDING91
tion department. + ADDRESS 6i ) L• l _Date —�-� ApplisCITY' Tem 1e Cit zIP 917LOCALITY
NO.OF BLDGS. NEARESTCERTIFICATE OF EXEMPTION.FR W 'KE `SIZEOFLOT 87000 NOW ON LOT• CROSS ST.
COMPENSATION INS NCE . ASSESSOR
(This section need not be completed if the permit is for one 't TRACT 4 313 6 BLOCK LOTRNO: MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) TEL.OWNE USE ZONE MAPIWeStCO la NO NO. 14
I certify that in rhe performance of the work for which this1!}25 Melannie Lan epermit is issued, I shall not employ any person in any maSPECIAL >_
nner s ADDRESS — CONDITIONS n-
so as to•become subject to the•Workers'Compensation Laws. O
CITY arcadiazIP 910u
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER $am a NO. DIS RIOT GROUP TYPE FIRE PROCESSED BY O
x CONST. ZONE
Exemption, you should become subject to the Workers' 7� h �y 1/
Compensation provisions of the Labor Code, you must forth- :.�ADDRESS J . 3 t/ 3 W
a
with comply with such provisions or this permit shall be TEL. •STATISTICAL.CLASSIFICATION APT. CONDO. to
deemed revoked.' CONTRACTOR Same NO. z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.C�lp I DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 2 6 5
(commencing with Section 7000)of Division 3 of the Business
LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. .. CITY CLASS ` BK PG VALIDATION
L� SO. Fi NO OF NO OF CHECK
License Number �86/ Lic. Class SIZE 2 05 0 STORIES 2 FAMILIES 1 ONE
' f VALUATION _ a.
`
ContracDate DESCRIPTION OF WORK Single f a m i l NEW � n. $ "^ .8,�. •
t _
❑I am exempt under Sec. ADD ❑ - ► _ _ .
ALTER ❑ -r i -
B.&P.C. for this reason g4 ra e• REPAIR ❑ $ -•• i-_ - I_)_..:
USE OF. ! til.00 0
Date: EXISTING BLDG. Sin• , e Famil ResJ rPEMOL ❑ v „_ `:
APPLICANT -"
Signature (PRINT] George WIEGAND NO.86-3636 `' FINAL
OWNER-BUILDER DECLARATION DATE 11 t
I her affirm that I am exempt from the Contractor's License Melanie lane Arcadia :'E. U /�
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL y4
Professions Code): PRESENT By
, .
El 1, as owner of the.property, or my employees with AD RPNSS
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 proCONTRACTOR NO.
property,am exclusively contracting '
with licensed contractors to construct.the project (Sec-
ADDRESS
tion 7044, Business and Professions Code.)
'CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROPALIINE FROM EXIST:
I hereby affirm that there is a construction lending agency for FRONT
the performance of.the work for which this permit is issued y. P.L.
(Sec. 3097, Civ..C.). SIDE- YT t.t
P.L•. W CI. GJ
Lender's Name B B H mortgage % Q Q /J�/ -.L --4
S I' P:C. Fee$' r Permit Fee V 3 J ° /1 LDMA ' by
Lender's AddresO.3 8 3 Wilshire Beverly H•i 11 / {y g� ® i
G•- 3 . /(J (f DMA P/C 0 X31
I certify that I have read this application and state that the Issuance Fee
above information is correct.I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee. a LDMA Perm.N
and hereby authorize'representatives of this County to enter
g upon the above-mentioned property for,inspection viposo. _ t.+ r.. %0 F,
o ��G�.--..C'• U�.•�� B SEE REVERSE FOR EXPLANATORY LANGUAGE �+ o e'� e0 0"
SI re of plica or t D e xp-+� G p g O IL" n