HomeMy Public PortalAbout9816 RICHMOND WAY_Building__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I have certificate of consent self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Se3800, Lab. C.) I a
�� USF&G COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. a � mpany
❑ Certified co is hereby'
furnished. FOR APPLICANT TO FILL IN BUILDING
PY Y / ADDRESS ��/rf� ll-6�/�YL��✓ !�/�"�
FLI Certified copy is filed with the county building inspec- gppRPNSs
tion department.
Date
—23-89
Applica /���/ � CITY Tiem 1 e City ZIP 917 8 0 LocAUTY
NO.OF BLDGS. o NEAREST y/ Ile
CERTIFICATE OF EXEMPTION d6M ORt R SIZE OF LOT R7000 NOW ON LOT
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT 4313 6 BLOCK LOT 4.Q. 6 d MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) OWNER Westco land IncTEL.. No•286-3636 No.
USE ZONE MAP _
I certify that in the performance of the work for which this 1425 Melanie Lan e
permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL
CONDITIONS CL
so as to become subject to the Workers'Compensation Laws. O
CITY Arcadia ZIP 91006
Ix
Date Applicant ARCHITECT OR TEL. DI TRI CT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Same NO. CONST. ZONE n t—
Exemption, you should become subject to the Workers' f�; Y,, '? C l _�
Compensation provisions of the Labor Code, you'must forth- ADDRESS a
l., d� , a-
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSI ICATION APT, CONDO. N
deemed revoked. CONTRACTOR Same NO. Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NOf DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 265864 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION
G SQ. FT. NO OF NO. OF CHECK
License Number Lic. Class SIZE 216 0 OF 2 FAMILIES ONE VALUATION
Conir � ate DESCRIPTION OF WORK Single F am i 1 NEIN $ _
�/ Residential attached 2ca ADD ❑ ► _:=.`:=
❑I am exempt un- r Sec. _
ALTER ❑
B.BP.C. for this reason Garage. REPAIR ❑ $/ —Ji—
USE OF D O D =- 4
Date: EXISTING BLDG.Single Familye s i d DEMOL ❑ _
Signature APPLICANT G e o r e W i e and TEL FINAL _ - +
OWNER-BUILDER DECLARATION (PRINT) g g N6.286-3636 DATE �I.. • -'l..'
I hereby affirm that I am exempt from the Contractor's License 14 2 5 Melanie Lane n.e
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT B _ -
❑ I, as owner of the property., or m employees with BUILDING Y
P P }Y� YADDRESS
wages as their sole compensation,will do the work and , n
the structure is not intended or offered for sale(Section LOCALITY V
7044, Business and Professions Code.) MOVING TEL.
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. 1
with licensed contractors to construct the project (Sec- ADDRESS ,
tion 7044, Business and Professions Code.).
CONSTRUCTION LENDING AGENCY SETABACK YARD HWY TOTAPROPLIINE FROM WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this p%T s issu 4 P.L.
(Sec. 3097, Civ. C.). .� : SID C. i
Lender's Name BBH Mortgage ti P.LC s-' r:3
$ . Fee$b Permit Fees 607.
LDMA Ref.
Lender's Address 8383 Wilshire Beverly Hit c»
§ to ,
I certify that I have read this application and state that the Issuance Fee' LDMA P/C#
above information is correct. I agree to comply with all County veatigation e
3� ordinances and State laws relating to buildin co ruction, Total Fee _ V11I! LDMA Perm. #
and hereby authorize representatives of this Cnto enter
upon th above-mention d r art Wf * action �ok.� EQ r-3Y � PGJ 6.7 C7
o / " O SEE RE1ASE FOR EXPLANATORY'VANGUAGE , y
Si ure of ppli my gent .Cry "•L '-g NJ