HomeMy Public PortalAbout9727 WINDSOR LN_Building__ „WORKERS'COMPENSATION DECLARATION
herzby affirm that I have certificate of consent to self
i APPLICATION FOR BUILDING P E RM I T
nsuret:br a certificate of Workers'Compensation Insurance,
tor-o certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NJA2R0143gR2Company Ri remans Fti d (� J .
❑ P Y FOR APPLICANT TO FILL IN oUILDIN ADDRESS -[7�7 �✓ /
Certified copy is hereby furnished. /ill OS(�lL, 61,
® Certified copy is filed with the county building inspec- BUILDING 1 r
tion department. ADDRESS ��-( 1111 W. Tnt, 11 Plan D Eley B
Date O/049 Applicant 'f i CITY ZIP 9178n LOCALITY SW corner Golden West &
CERTIFI TE OF EXEMPTION FROM WORKERS' NO.OF BLDGS.SIZE OF LOT Irre NOW ON LOT CRONEAREST
COMPENSATION INSURANCE T. limier Azusa
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT 434R Q BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL.OWNER Owen Construction NO. 575-0503 NO.
USE ZONE MAP
1 certify that in the performance of the work for which this SPECIAL �
permit is issued, I shall not employ any person in any manner ADDRE554275 Baldwin Ave �^/ CONDITIONS O
so as to become subject to the Workers'Compensation Laws.
CITY El Monte ZIP 91731
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER e- NO.33 - 60 DISTRICT G UP TYPE FIRE ZrID BY
Exemption, you should become subject to the Workers' � A� �� CONST• ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS 529 S Hollenbeck s(J ✓
with comply with such provisions or this permit shall be
TEL STATISTICAL CLASSIFICATION APT. ONDO.
deemed revoked. CONTRACTOR Owen ConstructionNO.575-0503
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. ��a DWELL. UNITS-2t I
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 B BK PG VAS 1jjQ .� A
SQ.FT. NO.OF NO.OF CHECK
License Number 444758 Lic.Class R SIZE STORIES FAMILIES ONE
NEW VALUATION ?x o 0 0 0
Contract -Date DESCRIPTION OF WORK New Single FamilyADD ❑ $ 1 4
, ' ° 4 U G 6 2
ElI am exempt under Sec. Home with attached garacte ALTER El❑ $ a a4 � (&62
B.BP.C. for this reason REPAIR
Date: EXISTING BLDG.USE OF DEMOL E] (I t1 2 S 8 6
Signature APPLICANT TEL FINAL
OWNER-BUILDER DECLARATION PRINT (Ven Construction NO. 575-0503 DAT r
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FI
Professions Code): PR NT !'
El '. as
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 _
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SETQBACK YARD HWY TOTAPROP LINER WIDTH 5 7 a O{L
I hereby affirm that there is a construction lending agency for FRONT ! r, 0 0 o c
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE f c 81 a 2 5
3 P.L.
e Lender's Name � 4 �� , 7� a o 6 •I C L 5 cT+
o LDMA Ref. #
P.C.Fee$ Permit Fee ' I Q,`U_ 6
- Lende s Address
ei J`� LDMA P/C#
I certi that I e read this application and state that the 1 b Issuance Fee
3 above ipform io is correct. I agree to comply with all County Investigation Fee
3 ordin races d tate laws relating to building construction, Total Fee -x LDMA Perm. #
and Aeby ut orize epresentatives of this County to enter
up e a me oned property for inspection- purposes.
o SEE REVERSE FOR EXPLANATORY LANGUAGE
O
Signator of Applicant or Agent Date i