HomeMy Public PortalAbout9723 WINDSOR LN_Building__ r d WORKERS'COMPENSATION DECLARATION
here�- insure,`oraafcertif caWorkers'that
te of have
tCompensation Insurance, APPLICATION FOR BUILDING PERMIT
or,o certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.WP8014398mpany Firemans Fund BUILDING 2 '
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS -72 jj)l oosep, Juj l
® Certified copy is filed with t e county building inspec- BUILDING Iry X12
tion department. ADDRESS 1 23 l /1ma Plan D, Elev A reverse
Date Applicant CITY Temple City zip 91780 LOCALITY SW corner Golden West &
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT IrreBLNOW ON LOT 0 CROSS ST.Lower Azusa
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT 43189 OCK LOT NO. MAP BOOK PAGE PARCEL
TEL. MAP
OWNER Olden Construction NOS=-@503 USE ZONE
I certify that in the performance of the work for which this 3?�� SPOECIAL —� �
3`_ /
permit is issued, I shall not employ any person in any manner ADDRESS 4275 Baldwin Ave. - I
so as to become subject to the Workers'Compensation Laws. CONDITIONS OP
CITY El Monte zip 91731 es
Date Applicant ARCHITECT OR TEL. DISTRICT G OUP TYPE FIRE CESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER CourtneyNO. 331-3060 CONST. ZONE
Exemption, you should become subject to the Workers' /` U
Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S Hollenbeck a iJ� -5 ®.
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. rNDO. g
deemed revoked. CONTRACTOR Owen ConstructionNO. 575-0503 �/qq �/��
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO.�l 62 DWELL. UNITS
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. PG VALjp.
SQ.FT. NO.OF NO.OF CHECK `a '�A
License NuAr 4447 Lic.Class B SIZE 2329 ISTORIES 2 FAMILIES 1 ONE
(� VALUATI N �/' / # o 0 0 02 3
Contracto Date "- DESCRIPTION OF WORK New Single Family NEW
10 ; Ib d'Q c 6b I a 4 8 O 6 2
I am exempt under Sec. Home with attached garage ADD ❑
ALTER $
o o [(�. 0 6
B.BP.C. for this reason REPAIR
Date: USE OF DEMOI ❑ 0 4'2 1 — 6
EXISTING BLDG.
Signature APPLICANT TEL. FINALATE
PRINT Owen Construction NO. 575-0503
OWNER-BUILDER DECLARATION D
1 hereby affirm that I am exempt from the Contractor's License _'5 7 0 2 A
Law for the following reason (Section 7031.5, Business and ADDRESS FIN
1.
Professions Code): PRE BUILDING B �� 0 0 0 0 : 3
❑ I, as owner of the property, or my employees with ADDRESS t ( ° 6 78.9 5
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. 0 0 J 4 y 5
CONTRACTOR NO. z
I,as owner of the property,am exclusively contracting •'. � (7 2 8-86
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED YARD HWY TOTAL SETBACK FRO �=5 7 9 3 h
CONSTRUCTION LENDING AGENCY SETBACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT tt o u o 0 0 1
the performance of the wor for which this permit is issued P.L.
(Sec. 3097, Civ. C' '
SIDE I ° $ 1 e ^5
P.L.
Q Lender's NameNIA ° c 'i v _ T
i� LDMA Ref. #
Lender's Addre s P.C. Fee$ , Permit Fee /• /V '
I certify that ave read this application and state that the �� 2 Issuance Fee
above infor tion' torr ct. I agree to comply with all County C,
ordinance nd tate I s relating to building construction, 0 D p Total Fee ® � � LDMA perm. #
u and her • ou orize epresentatives of this County to enter
upon t abov -me ion property for inspection purp ses. �® J_ -7
a Q 7-
Do do
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature pplicant or Agent Date