HomeMy Public PortalAbout9718 WINDSOR LN_Building__ WORKERS'COMPENSATION DECLARATION y
It{ertboy affirm that I have certificate of consent'to•self -- APPLICATION FOR BUILDING PERMIT 1
a certificate of Workers'Compensation Insurance,
certified copy thereof(Sec. 3800, Lab.'C.) '' COUNTY-OF LOS ANGELES 'BUILDING AND:SAFETY
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Certified copy is hereby furnished.•• FOR APPLICANT.TO FILL IN BUILDING G�
" _ ADDRESS D S O& I—/la
®' Certfied cop is filed with'tFie county bu idin un`spec- BUILDING
tion epart ertt: % ; • ADDRESS 7 ) ,V k ,(�ILOt 3 Plan H, Elev A
I
Date pplicant CITY _ ZIP 91780 LOCALITY.SW Corner Golden West &
C TIFI E OF•EXEMPTI.O M w6RKERS' -'NO.OF BLDGS.- •- NEAREST-
OMPE.IVSATION INSURANCE''f•�':• .1. i SIZE OF LOT Irre. NOW ON LOT 0 CROSS ST. LOV. r
(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
OWNER Owen' CO21SfSUCtlOn' No. 575-0503.1 USE ZONE MAP
I certify-that-in the.performance of the woik for which this NO, }
permit`1s issued,'1'shall-not employ any person in any,'mannersyn( SPECIAL-,
so as'to become subject to'the Workers"Compensation Laws. ADDRESS-4275,BaldWln.Ave-: ►` S CONDITIONS O
CITY El. Monte., zle 91731 _ _ 09
Date' ` Applicant ^�'' ARCHITECT OR TEL. O
NOTICE 7Q.-APPLICANT:.If, '6fter%making'•this• Certificate of ENGINEER COurtne.' NO. 331-3060 DISTRICT, GROUP TYPE FIRE PRO 5 _BY
Exemption,'.you 'should 'become' subject•to'"the.Workers' NS . �.
CO T Z E
Compensation provisions-of the Labor Code,•you•must•forth- ADDRESS 529-S. Hollenbeck ' `�-`�V R '•• fJ - ' • IL
w.ithncotnply;+with suchr provisions.or.this,permit. shall be , TEL STATISTICAL 'A
deemed revoked.,- , E4 ST CAL C IFI ATION.., APT. CO O.
t" CONTRACTOR NO. TAS/��/� 1
LICENSED CONTRACTORS DECLARATION • ',s -•• , -- - LIC; CLASS NO. v'" DWELL. UNITS ' P o O p
Lhereby affirm that I.am licensed under provisions of Chapter 9 ADDRESS. No444758 SEWER MAP
•(commencing withySection 7000)of Division 3 of,tlie Business and - -_ _ _. LIC; $� o 0 0 0 2 3
Professions'Cbde,and my license is in full force arid'effect. CITY CLASS B "' VALIDATION
SQ.FT. NO.OF ,•_ NO.OF CHECK•; BK. PG.
License Kliimber 444758 "'' l jc.Class i ` B' ' SIZE .2040 STORIES 2 FAMILIES' 1 ONE. :• �. ° 431,08
AJ' . . :, VALUATION .
Contractor Date DESCRIPTION OF WORK N2W Sln 'l.e FamilyNEW- -{ $ o 0 4 3.1.0 8�;
❑ I'am exem t under sec. Home-•with attached.• garage. ._. ADD ❑ 5 � 0 4,2.1 —8 6
P.. ALTER ❑ pill
B.BP.C.•for this reason REPAIR•❑ s "' " "'
" Date: USE OF DEMOL
,
EXISTING BLDG: ❑
Signature APPLICANT: TEL. FINAL
PRINT Owen. Construction Construction No. 575-0503 .
- OWNER-BUILDER DECLARATION _ ,., , _ _• ,,,•_ DATE -• � • y.• —• .
1 hereby affirm that I am exempt from-the Contractor's License,
Law for the following reason:(Section 7031.5, Business and ADDRESS F
Professions Code) PBRESENT
ING
• ❑ 1, as owner of the property, or my employees'with ADDR
wages-as their sole compensation,will'do the work and �- `'y;•.1 ,+; i• '''r �•
the structure is not intended or offered for sale(Section LOCALITY.
7044, Business and Professions Code). MOVING-
1,
OVING LOCALITY-
...TEL. ,.•, �,. ,• ' ; t ;
LJ. CONTRACTOR. NO.
I,as owner of the'.property,am exclusively contracting. ,:.a-�._� \r \ �"�i :. 4�•' `'
-with licensed contractors to construct the project (Sec-
ADDRESS .
tion 7044, Business and Professions Code).
REQUIRED._. TOTAL-SETBACK FRO T. 5 7-$-7•A
CONSTRUCTION LENDING AGENCY SET BACK YARD" HWY PROP.LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT ` • t� k i '. \`
the performance of the work for which-this permit is issued P.L.--
(Sec.
.L. -•' -••- ;� ` o d o o• 0 1 ,
(Sec.3097, Civ. C.). SIDE 1 -00 0 0
a P.L. A' . ti '•:::*< I ° 7 3:.J,
-Lender's Name
e LDMA Ref.'# o o 7 3-5 0 0 v
° P.C.Fee$- Permit Fee o�� -
Lender's Address
r I certify that I'have read this dpplimtion,and state.that.the . .. _. t O Issuance-Fee 0 •Sv CDMA P/,C# a 2'8:$6
ree to'com I Count ' -
= aboyte
rmation is correct. I ag. p y with all Y Investigation Fee
3 ardi ,and to laws relating to building construction, :. _ Total Fee db LDMA Perm.#
and. y th iYe representatives of this County to enter +
g� upob ve entioned property for inspection purposes. /oe
DA 4r.,
SEE REVERSE FOR EXPLANATORY LANGUAGE
•Sign e o +cont or Agent
1