HomeMy Public PortalAbout9707 WINDSOR LN_Building__ < t WORKERS'COMPENSATION DECLARATION
nsurebor afcertif carte of Wo ke s'tCompensation eInsurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
acyNo.WP80143982ompany Fir ?Man.9-&ndBUILDING '
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS A D,5 & Id,
L-1 Certified copy is filed wit7SFROM
my ding inspec- BUILDING '
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tion department. ADDRESS 7 D Lot 6 Plan �F, Elev A Reverse
Date ApplicanCITY ZIP LOCALITY SW Corner Golden West &
CERTIF CATE OF EXEMPTIWORKERS' Irre NO.OF BLDGS. NEARESTLOwer AZUSa
COMPENSATIONCE SIZE OF LOT g NOW ON LOT Y• CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT 189 BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. USE ZONE MAP
OWNER Owen Construction TE" 575-0503 / —Z
I certify that in the performance of the work for which this fJ NO. }
permit is issued, I shall not employ any person in any mannerI SPECIAL 916ADDRESS
so as to become subject to the Workers'Compensation Laws. 979 X1 CONDITIONS O
V
Date Applicant CITY El Monte zip 91731 �r
ARCHITECT OR TEL. O
NOTICE TO APPLICANT: If, after makin this Certificate of DISTRICT GROUP TYPE FIRE PRO SED BY
g ENGINEER - NO. I*
Exemption, you should become subject to the Workers' — O @ CONS`T/ ZONE U
Compensation provisions of the Labor Code, you must forth- Ron
ADDRESS 529 S Hollenbeck `-' ' 7�' �/ ,3 �
with comply with such provisions or this permit shall be PA
deemed revoked. CONTRACTOR Owen Construction No.575-0503 STATISTICAL CLASSIFICATION y' APr. NDO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 06 DWELL. UNITS-!!t/—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS No. 444758 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 BK PG VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License ber. 444758 Lic.Class B SIZE STORIES 2 1 FAMILIES 1 ONE
' DESCRIPTION OF WORK New Single FamilyNEW VALUATION
Contract r Date
❑ I am exempt under Sec. Home with attached garage ADD $ q�
-' ALTER ❑ 4 118,3 A
B.BP.C. for this reason REPAIR ❑ $ # o o o o 2 3
Date: USE OF DEMO' ❑
EXISTING BLDG. 1 - 661.73
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT) Owen Construction NO. 575 DATE< l �'� 661,735
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS nZ6,�
0t'!21 -36
Professions Code): PRESENT❑ 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.
CONTRACTOR NO. ` `•
❑ I, as owner of the property,am exclusively contracting
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). "
REQUIRED TOTAL SETBACK FROM I
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH -25 78.4 A
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. # 0 0 0 0 0 1
(Sec. 3097, Civ. C.). f^ SIDE o
P.L. I 7890(?
v Lender's Name / J LDMA Ref. # o o 789.000'
a Lender's Address P.C.Fee$ tp1��3 Permit Fee 2:24 <
> / '
I certify at I have read this application and state that the Issuance Fee / �� Jra LDMA P/C# 1028-86
above i rmafion is correct. I agree to comply with all County Investigation Fee
ordina s an t to laws relating to building construction, �S
and h by uth ize representatives of this County to enter Total Fee i �/ LDMA Perm. #
up ab ve- entioned property for inspection purposes.
(J SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur f Applicant or Agent pate i