HomeMy Public PortalAbout9821 RICHMOND WAY_Building__ WORKERS' COMPENSATION DECLARATION
hereby affirm That I have a certificate of consent to self APPLICATION FOR. BUILDING P E RM I T
insure, or a certificote•of Workers'.Compensahon Insurance,
.
or a certified copy there 9f. c. 3800, Lab. C.) j
0 L � '��•'•iI S F&G • I. COUNTY OF LOS ANGELES I BUILDING AND SAFETY
Policy No. _Copany -
❑' Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING • �� �h ,- /
ADDRESS
Certified copy is filed with.the.county building inspec- BUILDING
tion department. . ADDRESS f�t
Date
4:-23--8.9' � -cry- .Temple'• Cit ZIP 8
AppLOCALITY
ltc Q
CERTIFICATE OF EXEMPTION M RK SIZE OF.L018 7 O O O NOW ON LOT NO.OF BLDGS.. O NEAREST
CROSS ST. G
COMPENSATION.I URANCE ASSESSOR '
(This section need not-be completed if the permit is for one TRACT 4 313 6 BLOCK LOT O. 4 MAP BOOK PAGE PARCEL
hundred dollars.($100)orless,)
WeStCO Land Inc.' TEL' -363,
USE ONE
OWNER .I MAP
NO.
I certify,that in the-performance of the work for which this �'' NO.
ECIAL
perinit is.issued,'.d shall not employ any person to any manner ADDREJE4 2 5 ' Melanie Lane p
;'C ECTAL'-
NS XL
so as to become•subject to the,Workers'Corripensatiori Laws. f •O
CITY. Arcadia "ZIP 9.1006 I " v''
Date ApplicantARCHITECT OR TEL. DI$TRICf I GROUP ITYPE FIRE F,9QCESSED BY O
NOTICE'TO APPLICANT: If, after making this',Certif!cote of ENGINEER' Same NO. ,/ CONST.
ZONE Exemption, you%should become subject to the Workers' 0 `�
Compensation provisions of the Laboi Code, you must forth- -ADDRESS . : t �FIL
with comply with;such .provisions or this permit shall be. TEL. STATISTICAL CL4SSII;ICATION. APT. CONDO. N
deemed revoked. CONTRACTOR' Sam a NO. ` Z
' LICENSED.CONTRACTORS.DECLARATION UC- 265864 CLASS Nd�k _DWELL.•UNITS .
I hereby affirm that'I am licensed under provisions'of. ADDRESS NOf•Chapter 9 SEWER MAP
(commencing with.Section 7000)-of Division 3 of the'Busine'ss LIC.
and Professions Code,and_my license is in full force and effect. CITY CLASS B BK PG VALIDATION"
SQ. FT. NO.OF NO.OF CHECK
License Number Z� � `Lic. Class SIZE 2 3 O O STORIES 2 1 FAMILIES I ONE 1�I VALUATION
Contracto(�r� to DESCRIPTION OF WORK NEW t-1 a i -
R.es d.eiitial attached' 2car 'IDD ❑ , - ='"
❑I am,exempt under Sec. °` -
ALTER ❑ 71k
B.&P.C. for this reason G.ara e.. ;
USE OF, . REPAIR ❑ Q a '
QQ , _y
• .Date: - .. - � DEMOL•❑ U)
EXISTING BLDG. '
Si APPLICANT APPLICANT TEL. ,_u� ,
(PRINT). George W i e g a n d No, - 286-363 FINAL ,r�
OWNER-BUILDER DECLARATION DATE.
I hereby affirm-that I am exempt from the Contractor's License '•"'r' '-
Low for--the following reason.(Section 703115, Business'and ADDRESS14 2 5 Melanie L a 11 a Ar C a d i a. FINAL '.
Professions Code):,' PRESENT. By
❑ I, as owner of-the property, or m employees.with BUILDING i. r1
P P Y� YADDRESS ': ••
wages as their sole compensation,will.do the-work and ! _
the structure is not intended or offered for sale(Section LOCALITY Poo �c-
7044,.Business and Professions Code.) ' MOVING ' TEL.
CONTRACTOR NO. O
❑ 'I,as owner of the property,am exclusively contracting
with licensed contractors td construct the project'(Sec- ADDRESS I "{
tion 7044, Business and Professions,Code. •.
CONSTRUCTION LENDING AGENCY ) REQUIRED YARD HWY' TOTAL SETBACK FROM EXIST.
ET BACK PROP. LINE WIDTH.
I he�eby'affirm that there is a construction lending agency for FRONT �(t\.
the performance of the-work for which this permit is•tssued P.L.
(Sec. 3097, Civ. C.). SIDE ,
µ
Lender's Name R R N M n r t a•u a pp� 9E F9 a
$ g. C� - / �LDIYIA Ref. '�+�•-' _J U•,
P.C...Fee.S Permit Fee / /�
Lender's Address R R'1 W i l 'g h i"re R a v a r 1 � H 111 ��
I certify that I.have read this application and state that the i Issuance Fee t� LDhAs4 P/C#•
above information is correct.I agree to comply with all County' Investigatio F ;
ordinances and State laws relating to building construction, ITotal Fee Q. LDMA Perm.•#
and hereby authorize representatives of this County to/Pent
upon the above-mentioned pro erty for insp ction urpo s. �
'SEE REVERSE FOR EXPLANATORY LANGUAGE 00
n y G o
Signal of Aptcan r�Ont g %4D