HomeMy Public PortalAbout9719 WINDSOR LN_Building__ WORKERS'COMPENSATION DECLARATION
APPLICATION FOR BUILDING PERMIT
•Oiereby affirm that I have a certificate of consent to self,
insureor a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lob. C.)
Policy No.WP80I 43982ompany Fi remans Fund COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
® Certified copy is filed with t1A county building inspec- BUILDING
tion department. ADDRESS 7 nl QST fZ Lot 9 Plan H, Elev B Reverse
Date Q6 Fi� Applicant L91t . CITY Temple City zip 91780 LOCALITY SW corner Golden West &
CERT FICATE OF EXEMPTIOVFROM WORKERS' NO.OF BLDGS. NEAREST
'
COMPENSATION INSURANCE SIZE OF LOT Irre NOW ON LOT 0 CROSS ST.Lower Azusa
(This section need not be completed if the permit is for oneASSESSOR
hundred dollars($100)or less.) TRACT 43189 BLOCK LOT NO. MAP BOOK PAGE PARCEL
N
OWNER Owen Construction o. 575-0503 USE ZONE MAP
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any mannerSPECIAL
ADDRESS 4275 Baldwin Ave tt CONDITIONS
so as to become subject to the Workers'Compensation Laws. 0
Date Applicant CITY El Monte zip 91731 05
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PR C SED BY O
ENGINEER Courtney NO. 331-3060 a
Exemption, you should become subject to the Workers' ��j y� CONST. ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S Hollenbeck �' r (t 3 3 �
with comply with such provisions or this permit shall be =
deemed revoked. TEL STATISTICAL CLASSIFI ATION APT:= CA DO.
CONTRACTOR Owen Construc'tionNO. 575-0503
LICENSED CONTRACTORS DECLARATION LIC_ CLASS NO. DWELL. UNITS #! c ° ° .S
1 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 PG VALIDATION I
SO.FT. NO.OF NO.OF CHECK
License Nu er 444758 Lic.Class B SIZE 2 STORIES 2 FAMILIES 1 ONE °
/ VALUATION
Date ` G — DESCRIPTION OF WORK NEW ® $ ,'�/ 0 OIL 2 1 —P6
Contractor ❑
ADD
❑1 am exempt under Sec. Home with attached cfaracTe ❑
ALTER
B.&P.C. for this reason REPAIR ❑ $
USE OF
Date: EXISTING BLDG. DEMO! ❑ eet--7II
Signature APPLICANT TEL. FINAL mss/
OWNER-BUILDER DECLARATION PRINT Owe o struction No. 575-0503 DATE - I�
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FIN
Professions Code): PRESENT B
❑ BUILDING j
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.
❑ CONTRACTOR NO.
I, as owner of the property,am exclusively contracting 9 •�
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTAPREOTPAINEFROM WIDTH rJ 7$ A
I hereby affirm that there is a construction lending agency for FRONT
0 0 0 0 0 1
the performance of the work f r which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L. 1 ° 75500
Lender's Name
$ LDMA Ref. # ° ° 7 5 5. J U
Lender's Address P.C.Fee$ Permit Fee ,.`,!' '
I C28�-86
I certify th ;have read this application and state that the 131,bIssuance Fee ��� LDN P/C#
above info tion i orrect. I agree to comply with all County Investigation Fee
$ ordinance a d to lows relating to building construction, Total Fee
u and here y u oriz representatives of this County to enter �. LDMA Perm.#
upon the a ov -m tioned property for inspection purposes.
i SEE REVERSE FOR EXPLANATORY LANGUAGE
Si natureo pplicant or Agent Date