HomeMy Public PortalAbout9722 WINDSOR LN_Building__ 'WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT �
insure, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy►�18IP8011.1�398t�mpany FlremariS and BUILDING---v I
COUNTY OF LOS ANGELES BUILDING AND SAFETY 1
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 1& ruz C/ 03,')& /.
® Certified copy is filed with th county building inspec- BUILDING Aq
tion department. /� ADDRESS �2 056Lot 2 Plan F, Elev B
Date pelican �"��¢ CITY ZIP LOCALITY SW corner Lower Azusa &
CERTIFIC TE OF EXEMPTION FROM WORKERS' SIZE OF LOT Irreg NOW ON LONO.OF TS Jv cNEARESS
COMPENSATION INSURANCE T. Golden West
(This section need not be completed if the permit is for one I11' o18 ASSESSOR
4
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
OWNER Owen Construction No. 5750503 USE ZONE MAP
I certify that in the performance of the work for which this n NO.
permit is issued, I shall not employ any person in any manner ADDRESS 275 Baldwin Ave Ar — I SPECIAL d
so as to become subject to the Workers'Compensation Laws. YYW"Y`�� CONDITIONS 0
Date Applicant CIT)E1 Monte Ca. ZIP 91731 A9
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR. TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0
ENGINEER (;Ourrne No. 331-3060 CONST. ZONE
Exemption, you should become subject to the Workers' '/
Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S. Hollenbeck 5A�� R--3 Y 3 y
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. NDO, z
deemed revoked. CONTRACTOR Owen Construction NO. 575-0503
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO.00 DWELL. UNITS
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 CLASS BK PG VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License Number 444758 Lic.Class B SIZE 2216 STORIES FAMILIES ONE
VALUATION F(G I rl
� 6'k Or �--� DESCRIPTION OF WORK NEW ® L A
Contractor ,�'� rr��I� ,
(N"`^ Date ADD ❑ s � � � � 0 0 0 0 �v
❑I am exempt under Sec. Rome attached Gara-e ALTER ❑ , o o 6 3.Z.
B.BP.C. for this reason REPAIR ❑ $
Date: USE OIF BLDG. DEMOI ❑ /+ o o463,2 1 T
Signature APPLICANT TEL. FINA �s1 Q Q L —6 6
OWNER-BUILDER DECLARATION PRINT) Olden Construction N0.575-C�Q3 DATE _g
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 ./
El1,
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 o 5 7 8 O A
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY ED TOTAL SETBACK
LINE F M WIDTH # 0 0 0 0 0
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 7 8 9, :' `J
(Sec. 3097, Civ. C.). SIDE
NI a a
P.L.
Lender's Name _ LDMA Ref. # ) (),L 8 6
P.C. Fee$ i Permit Fee
Lender's Address / '
I certify that have read this application and state that the 63r oZ / Issuance Fee ¢' 5`0 LDMA P/C#
above in tion is correct. I agree to comply with all County Investigation Fee
ordinance nd St a relating to building construction, Total Fee / 0 Q LDMA Perm. #
and here taut rize r reseFtatives of this County to enter
( upon the Gov menti operty for inspection pur oses.
�iL( / �e,� SEE REVERSE FOR EXPLANATORY LANGUAGE
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�gnature of pp icant ix gen / Dares