HomeMy Public PortalAbout9711 WINDSOR LN_Building__ yJORKERS'COMPENSATION DECLARATION c�
r, o affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT +ISI
insure, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoWP80143982:ompany Fi reman_ Fund—
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS !tl S
® Certified copy is filed with th unty build*n inspec- BUILDING
tion departme t. ADDRESS rot 7 Plan E, Elev A reverse
Date plicant t, CITY Tam le City zip 91780 LOCALITY SW corner Golden West &
CERTIFICATE OF EXEMPTION FROM WORKERS' Irre NOW ON LOT NEAREST
SIZE OF LOT
COMPENSATION INSURANCE 0 CROSS ST. Lower Azusa
(This section need not be completed if the permit is for one ASSEOR
TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
.hundred dollars($100)or less.)
TEL. USE ZONE FSPEN�;IAL
_7
I certify that in the performance of the work for which this OWNER NO. — (�V
911.permit is issued, I shall not employ any person in any manner ADDRESS 4275 Baldwin- Ave. DITIONS
so as to become subject to the Workers'Compensation Laws.
G;
CITY El Monte zip 91731 ad
Date Applicant ARCHITECT ORTEL• DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Courtney NO, 331-3060 CONST. ZONE b
Exemption, you should become subject to the Workers' 6-•bg 19 z 3 M
Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S H011enbeCk v0 t --i @,
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. NDO_
deemed revoked. CONTRACTOR Olden Construction NO. 575-0503 J���
LICENSED CONTRACTORS DECLARATION LIC' 444758 CLASS NO.�,/SL—DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 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
SQ.FT. NO.OF NO.OF CHECK
License Nu r Lic.Class R SIZE 2352 STORIES 2 1 FAMILIES 1 ONE Ap 4 5 0 3 A
VALUATION '
Date Q d2 DESCRIPTION OF WORK New Single Family NEW $ � 0 0 0 0
Contractor � (J Q d$ # 2 3
Home with attached. -arae ADD O , 1 0 4 8 3,2 9
❑ I am exempt under Sec. ALTER
B.BP.C. for this reason REPAIR ❑ $ 0 0 4 8 3.2 9 6
Date: USE OF DEMOL ❑
EXISTING BLDG. 0 Q,21 —86
Signature APPLPRI TT Oven Construction NO.575-0503 FINAL z
OWNER-BUILDER DECLARATION DATE 7 ,3
I hereby affirm that I am exempt from the Contractor's License
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 I
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 YARD HWY TOTAL SETBACK FROM T.
CONSTRUCTION LENDING AGENCY SET BACK PROP.LINE WIDTH 2 5 7$3 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
(Sec. 3097, Civ. C.). SIDE
Lender's Name tT "! P.L. q 1 0 $2 2 7 5
LDMA Ref.,#
P.C. Fee$ Permit Fee aJ 0 0 8 2 2 7 5 5
Lender's Address
8'3 2
• I certify that I have read this application and state that.the Issuance Fee LDMA P/C# I Q 2.8—86
obov infor on is correct. I agree to comply with all County Investigation Fee
ordi nc an State laws relating to building construction, Total Fee #715 LDMA Perm. #
and er y a horize representatives of this County to enter
u the abo e- ntioned property for inspection purposes.
�� Q` � SEE REVERSE FOR EXPLANATORY LANGUAGE
01
Sig re of Applicant or Agent Date