HomeMy Public PortalAbout9712 WINDSOR LN_Building__ WORKERS'COMPENSATION DECLARATION
hereby firm tcertificate �naofirue'orlicertifcate of Wokes' pensaton consent toself APPLICATION FOR BUILDING P E RM I T
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.WPA01 43982ompany Pi ramana Ftlnr9 BUILDING l
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS � ? ,4A Lot 4 Plan Lr Elev A reverse
Dare Applicant cITY Tem' le Cit- zIP 91780 LOCALITY SW corner Golden West &
CERTIFICATE OF EXEMPTI FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT Irre" NOW ON LOT CROSS ST. Lower Azusa
(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
I USE ZONE
OWNER Owen Construct' No. 5 5- 5 MAP
1 certify that in the performance of the work for which this NO.� >_
permit is issued, I shall not employ any person in any manner SPECIAL IL
so as to become subject to the Workers'Compensation Laws. ADDRESS 4275 Baldwin Ave CONDITIONS
V
•- CITY ZIP ad
Date Applicant ARCHITECT OR TEL. 0
NOTICE TO APPLICANT: If, after making this Certificate of — DISTRICT GR UP T../TYPE FIRE TPSSED BY
Exemption, you should become subject to the Workers' ENGINEER e" NO• CONSZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S. HO lenAeck Y J R'
with comply with such provisions or this permit shall be - g
deemed revoked. TEL. STATISTICAL— CLASSIFICATION APT, rONDO,
CONTRACTOR a NO. CLASS NO.. U.. UNITLL
LICENSED CONTRACTORS DECLARATION LIC,
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 CLASSBK ��VALIDAT)QJd, A
SQ. FT, NO.OF NO.OF CHECK
License Nu r 444758 Lic.Class B SIZE 211 STORIES 2 FAMILIES 1 ONE
n VALUATION ® # o 0 0 0 23
Contractor Dot 0 ' DESCRIPTION OF WORK New Single FaMilV
NEW
D $ q 16 3 0 5
❑ o
❑I am exempt under Sec. Hme witb attacbed garage _
ALTER ❑ 0 ° 63305c
B.BP.C. for this reason REPAIR $
Date: USE OF DEMOL ❑ 0 k2 1 -86
EXISTING BLDG.
Signature APPLICANT TEL FINAL
OWNER-BUILDER DECLARATION PRINT Owen Construction No, 575-0503 DATE
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS F1
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.
❑ 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). -2 5 7 8 6 A
REQUIRED TOTAL SETBACK FROM I
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 0 1
the performance of the work for which this permit is issued P.L.
(Sec. 3097, civ. C.). o 0755255 SIDE I a 7 5 5 2 5
a P.L.
v Lender's Name LDMA Ref. #
° P.C.Fee$ cJ Permit Fee L 7� ' 0,28-86
Lender's Add ess I
r I certify th I have read this application and state that the Issuance Fee U• J`� LDMA P/C#
above info ation is correct. I agree to comply with all County Investigation Fee
3 ordinance and a laws relating to building construction, Total Fee 7,J76-, � LDMA Perm. #
J and here a ori representatives of this County to enter
upon b e-m ntioned property for inspection purposes.
a
c1;,r_ i� SEE REVERSE FOR EXPLANATORY LANGUAGE
411219 notu r Applicant or Agent Date t