HomeMy Public PortalAbout9801 WINDSOR LN_Building__ W9RKERS' COMPENSATION DECLARATION \
insure, or acertificate affirm
of Workers' Compensation eInsuran elf APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Spec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nbl"CY O eZ') 1 �o mp�any641 S 42�6
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
QCertified copy is filed with the county building inspec- BUILDING l
tion department. ADDRESS /l/ re
�-r CITY C 1 t y ZIP LOCALITY
Date—2 —g� Applic� NO. OF BLDGS. NEAREST 16.65
CERTIFICATE OF EXEMPTION F WOER SIZE OF LOT 8 7 0 0 0 NOW ON LOT*
1rf
COMPENSATION INS NCE ASSESSOR
(This section need not be completed if the permit is for one TRACT4 313 6 BLOCK LOT NO. MAP BOOK PAGE AfJEL
hundred dollars ($100)or less.) Land Inc C . TEL. 287--3636 USE ZONE MAP
AG
OWNER NO.
I certify that in the performance of the work for which this NO. a
permit is issued, I shall not employ any person in any manner ADDRESS 1425 Melanie 1ane —.J SPECIAL 97a--t
CONDITIONS 2
so as to become subject to the Workers'Compensation Laws. O
cITYArcadi a zip 91006 TOTAL f u
Date Applicant ARCHITECT OR TEL. DI TRICT GROUP TYPE FIR R CESSED BY 1.9lei
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. / CONS7. ZOtJF i 1r-r �;
Exemption, you should become subject to the Workers' .� /
Compensation provisions of the Labor Code, you must forth- ADDRESS �/ Cp� )
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. �CONDO.deemed revoked. CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS _
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 1�CS'
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP 11v�EiG a
and Professions Code,and my license is in full force and effect. CITY CLASS B i AM 9:0
BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number 7 v 6 Lic. Class ZS SIZE STORIES FAMILIES 1 ONE
Single e f a m i 1 VALUATION
Contractor • ate DESCRIPTION OF WORK g y NEW {Kp�'1 J $
❑1amexemptunderec. Residential attached 2car ADD El ►
ALTER ❑
B.BP.C. for this reason ❑ $
REPAIR a C o�ry V o
USE OF
Date: EXISTING BLDG. Single family R e s i EMOL ❑
Signature OWNER-BUILDER DECLARATION APPLICANT TEL..(PRINT) George Weand 286-3636 FINAL
NoDATE 2''1 L q
<�
I hereby affirm that I am exempt from the Contractor's License ADDRESS � e Lane e
Law for the following reason (Section 7031.5, Business and FINAL
Professions Code): PRESENT By
El
BUILDING
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- rADDRIgSS ,
tion 7044, Business and Professions Code.)
CONSTRUCTION LENDING AGENCY ACK YARD HWIRED TOTAPROPALINEFROM WIDTH
1 hereby affirm that there is a construction lending agency for T
the performance of the work for which this permit is issued(Sec. 3097, Civ. C.).lender's Name RRH Mortgagep O gR JS.Lender's Address R'1R'i Wi l Ghi rP RPVPr1 V hlle Permit Fee LDMA Ref. #I certify that I have read this application and state that the Issuance Fee d.sQ LDMA P/C#
above information is correct. I agree to comply with ail County ,
ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
r and hereby authorize representatives of this County to enter
upon the above-mentioned prorty for ins tion pur os
� SEE REVERSE FOR EXPLANATORY LANGUAGE
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