Loading...
HomeMy Public PortalAbout11201 WINDSOR LN_Building__ 1,1 • WC 9KERS'COMPENSATION DECLARATION herby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT � insure, or a certificate of Workers'Compensation Insurance, j. or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No pM14,3c) pony-F�i rPManS Fund 14 ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN Ao R SS et"� (,{J /V 0509 IL/ll. Certified copy is filed with the county building inspec- BUILDING qZ/ r tion depar ment. ADDRESS 7! {� © Sdf, Lot 1 Plan F', Elev A Date Applica nt 64AIT CITY Tem le City ZIP 91780 LOCALITYSW corner Lower Azusa & Gold CERTIFidATE OF EXEMPTION FROM WORKERS' Irre NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LO11T,, pp g NOW ON LOT CROSS ST. Golden West (This section need not be completed if the permit is for one W31U7 BLOCK LOT NO. ASSESSOR hundred dollars ($100)or less.) TRACT MAP BOOK PAGE PARCEL TEL USE ZONE MAP OWNER n NO. —Q O ^�. >. I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in any manner11 SPECIAL IL so as to become subject to the Workers'Compensation Laws. ADDRESS 42 Baldwin Ave. I CONDITIONS V CITY ZIP Q 731OC Date Applicant ARCHITECT O TEL. O NOTICE TO APPLICANT: If, after making this Certificate of '431-3 DISTRICT GROUP TYPECONST. ZONE JESSED BY Exemption, you should become subject to the Workers' ENGINEER Ourtn NO. 1- QQ Compensatin provisions of the Labor Code,.you must forth- ADDRESS 5t 6 9--3 ✓ � with comply with such provisions or this permit shall be us TEL STATISTICAL CLASSIFICATION APT. rONDO. us deemed revoked. CONTRACTOR Owen Constructilgl i LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N0.44 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 444750 B SIOZES .'2 6 INO. NO.S ORIIES 2 FAMILLIIES 1 HECCO EK License Number Lic.Class �J � #y-t VALUATIO7m4lo Contractor DESCRIPTION OF WORK NEW Date F-1 I am exempt under Sec. Famil Home with attached AD° ❑ ; �j Poo. ALTER ED] 0 0 0 o f j B.BP.C. for this reason SE OF REPAIR ❑ ; ( o463,21 Date: EXISTING BLDG. DEMOL ❑ Signature APPLICANTTEL. FINAL ° ° 4 6 3 G 1 u OWNER-BUILDER DECLARATION (PRINT) Owen ConstruCtlomb. DATE I hereby affirm that I am exempt from the Contractor's License r () Ll,21 —C 6 Law for the following reason (Section 7031.5, Business and ADDRESS FI Professions Code): PRESENT ❑ BUILDING I, as owner of the property, or my employees with ADDRESS 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. e ❑ 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). REQCONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP. LINE CK FRO 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. r 7 Y a (Sec. 3097, Civ. C.). SIDE —. o � 11 P.L. Lender's Name !V �� # 0 0 0 0 0 1 Z2 aLDMA Ref. # P.C.Fee$ Permit Fee 1 - Lender's Ad ss ^� � o ��9(, (, r I certify th I have read this application and state that the t Q • `JOU LDMA P/C# ' 3 Issuance Fee ° -7, () , = above inf ation i rr t. I agree to comply with all County Investigation Fee ordinonc s and to I s relating to building construction, Total Fee LDMA Perm. # J and her au orize presentatives of this County to enter ( ��.!c3'`V 6 I up t abo -men oned property for inspection p poses. c O SEE REVERSE FOR EXPLANATORY LANGUAGE D Signature plicant or Agent Dat 0 t