HomeMy Public PortalAbout9715 WINDSOR LN_Building__ ! !tv N,`'ORKERS'COMPENSATION DECLARATION
e l hereby a certificate
that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, p. a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoWPRnl4398 Company PiremanG F»nd BUILDING ! -----------
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Certified copy is hereby furnished. FLOT
R APPLICANT TO FILL IN ADDRESS r
® Certified copy is filed with t county building inspec- q-71,5-
tion
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tion department. 1� Lot 8 Plan L1 , Elev B
Date
Applicant Temple City
ZIP 91780 LOCALITYSW corner Golden West &
CERTIFICATE OF EXEMPTIO ROM WLORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE NOW ON LOT CROSS ST. Lower Azusa
(Thissection need not be completed if the permit is for one OR
TRACT 43189 BLOCK LOT NO. MAASSP BOOK PAGE PARCEL
hundred dollars($100)or less.) TEL.
OWNER OwenConstruction No. 575-0503 USE ZONE MAP
I certify that in the performance of the work for which this ) NO, y_
permit is i4275 B
ssued, I shall not employ any person in any manner SPECIAL A.
ADDRESS aldwin Ave / CONDITIONS O
so as to become subject to the Workers'Compensation Laws. U
CITY El Monte ZIP 91731 Rd
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER CourtneyNO.331-3060 CONST.: ZONE
Exemption, you should become subject to the Workers' / ( 4.3 / Ru
RuCompensation provisions of the Labor Code, you must forth- ADDRESS 4275 Baldwin Ave. `/
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION / APT. CONDO. g
deemed revoked. CONTRACTOR Owen ConstructiorNO. 575-0503 Jj
LICENSED CONTRACTORS DECLARATION LIC. _ CLASS NO. V O DWELL.UNITS--!L
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 444758
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions Code,and my license is in full force and effect. CITY CLASS B BK PGVALIDATION
SQ.FT. NO.OF NO.OF CHECK
License N er 4447 8 Lic.Class B SIZE 2110 STORIES 2 FAMILIES 1 ONE
NEW VA�/�TI� ,I O�
Contractor Date DESCRIPTION OF WORK New single famll � $ L �/
ADD
❑ I am exempt under Sec. home with attached arae ALTER F] oil, 20
B.&P.C. for this reason REPAIR ❑ $ a 4 3.
USE OF
Date: D a a 4 4 3 1 4 J
EXISTING BLDG.
APPLICANT TEL FINAL U 4.2 1 -86
Signature
OWNER-BUILDER DECLARATION (PRINT) Owen Construction NO. 5750503 DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FI L
Professions Code): PRESENT
❑ BUILDING t ,
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and t,
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).
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY IRED TOTAL SETBACK
LINE FR M WIDTH 5 7 T. 2 A
I hereby affirm that there is a construction lending agency for FRONT # 0 0 0 o a 1
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). J n SIDE •(, - 75525
e Lender's Name �1 LDMA Ref.'# 0 0 7 5 5 2 5 5
P.C. Fee$ L Permit Fee r 7
- Lender's ddress Opp,
al G28-86
rI certify at I have read this application and state that the �7 3, Issuance Fee •�� LDMA P/C#
above' f rmation is correct. I agree to comply with all County Investigation Fee r
ordin s a tate laws relating to building construction, Total Fee J . LDMA Perm.#
and r la aut rize representatives of this County to enter
upo t e ov -mentioned property for inspection purposes.
c
o / !/�j SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sig re of Applicant or Agent C D tro
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