HomeMy Public PortalAbout9708 WINDSOR LN_Building__ WORKERS'COMPENSATION DECLARATION
r I1here'y a�firm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT J,
in,ire, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.WP80143982ompany Firemans Fund
1:1 Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING /� /,,
PY Y ADDRESS f/ I'(/ S ��CI
99 Certified copy is filed with t county building inspec- BUILDING 4 4
tion department. ADDRESS Q iju06 L 4. , Lot 5 Plan J, Elev A reverse
Date plicCITY Temple City zip 91780 LOCALITY SW corner Golden West &
ATE OF EXEN FROM WORKERS' OF NEAREST
COMPENSAT INSURANCE SIZE OF LOT Irre' NOW ON LOT CROSS ST. Lower Azusa.
CERTIFI
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT 43189 BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. USE ZONE OP _Z /
I certify that in the performance of the work for which this OWNER Owen Construction No. 575-0503 ///� �j >
permit'is issued,I shall not employ any person in any manner ADDRESS 4275 Baldwin Ave. K_ I SPECIAL IL
so as to become subject to the Workers'Compensation Laws. ! CONDITIONS �
Dare Applicant CITY El Monte zip 91731 @s
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
ENGINEER Courtney No.331-3060 CONST. ZONE
Exemption, you should become subject to the Workers'
7.
Compensation provisions of the Labor Code, you must forth- ADDRESS r V ./ A.
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICA ION L J APT.
deemed revoked. CONTRACTOR Owen ConstructionNO. 575-0503 T
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 60—DWELL. UNITS
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 V IDI�TrO�IF a
SQ.FT. NO.OF NO.OF CHECK L7 0 l rf
License Nu r ' 444798 Lic.Class R SIZE STORIES FAMILIES ONE
NEW VALUATION �l ° �yam{itj 4•
Contractor Date DESCRIPTION OF WORK New S e Fa it ADD 0 $ N 2`qb L 7 _8
❑1 am exempt under Sec. ALTER ❑ 01111"
()
B.BP.C. for this reason REPAIR ❑ $
Date: USE OF DEMOL ❑
EXISTING BLDG.
Signature APPLICANT TEL, FINAL
OWNER-BUILDER DECLARATION PRINT Olden Construction No. 575-0503 DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS F AL
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT y
❑ 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.
❑ 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). REQUIRED TOTAL SETBACK FROM f 5 7 8 5 A
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT }' ° 0 0 0 0 1
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L. ° 8:J 8 `%5
Lender's Name f f r LDMA Ref. #
9 P.C.Fee$ Permit Fee
7 8 �
Lender's Address '
S D• S—v kLD P/C# I C.2 c'— 6
I certify that I ave read this application and state that the U 6 Issuance Fee
above inform t n is correct. I agree to comply with all County Investigation Fee G��i eJ�
$ ordinances State laws relating to building construction, Total Fee Q d ' LDMA Perm.#
u and hereby tho presentatives of this County to enter
upon the vme coned property for inspection purposes.
a J • �p SEE REVERSE FOR EXPLANATORY LANGUAGE
R
gnatur Applicant or Agent Date a