HomeMy Public PortalAbout9802 WINDSOR LN_Building__ WORKERS'COMPENSATIgiN DECLARATION
hereby affirm that I have r ce' Comte of consent to self APPLICATION FOR BUILDING P E RM I T
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof(Sec. 3 0, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. fl" O 8ompany U S F 1.(* BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Q& l%f�l� b2
® Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
Date 4-2 3-8 9 Applica ..� ,moo 4, CITY Temple Cit ZIP 91780 LOCALITY
`/ NO. OF BLDGS. O NEAREST
CERTIFICATE OF EXEMPTIONy OM W RKE S' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT4 313 6 BLOCK LOT NOr 1.6 MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) TEL.a USE ZONE MAP ,4}}/I 12� 7 L1
OWNER W e s t O NO — NO.
I certify that in the performance the work for which this 1425 Melanie Lane SPECIAL ?-
permit is issued, I shall not employ any person in any manner ADDRESSP,� CONDITIONS 0
so as to become subject to the Workers'Compensation Laws.
clnArcadia ZIP 91006 U
Date Applicant ARCHITECT.OR TEL. Ix
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Same NO. D)STRICT GROUP TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers' �� CONST. ` ZONE w
Compensation provisions of the Labor Code, you must forth- ADDRESS jj Y 3 CL.
withcomply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICgTION APT. CONDO. Z
deemed revoked. CONTRACTOR Same NO. / _
LICENSED CONTRACTORS DECLARATION LIC. 265864
CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and m license is in.full force and effect. CITY CLASS B BK. PG. VALIDATION
NO OF NO.OF CHECK
License Number Lic. Class SIZE 2 0 5 0 STORIES 2 FAMILIES 1 ONE
/ VALUATION
aL � DESCRIPTION OF WORK Silo n 1 e f a m i 1 NEW119
Contra cta�— ate ADD ❑
Residential Attached 2ca
$
Ele,(I am exempt undec. _
ALTER ❑
B.BP.C. for this reason garage . REPAIR ❑ $
Date: USE OF F-1 /A 0, D o a
EXISTING BLDG. Single MOL
Signature APPLICANT TEL
OWNER-BUILDER DECLARATION ,
(PRINT) George Wiegand NO. 286-363 FINAL
DATE Z-4 9/
I hereby affirm that I am exempt from the Contractor's License 14 2 5 Melanie lane Arcadia
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT By (�
❑ I, as owner of the property, or m employees with BUILDING
P P Y� YADDRESS ,
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.)
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
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.
(Sec. 3097, Civ. C.). SIDE. v '� , VCU\
P.L..
Lender's Name BBH MORTGAGE �/�jQp I .�� r a _J o
B 8383 Wilshire Beverly H7 P • Fee$ Permit Fee C70U, 7� MA da �/)
Lender's Address 3 -••I
I certify that I have read this application and state that the 4-3 3 �, Issuance Fee ��� LDMA P/C# ,
above information is correct. I agree to comply with all County Investiga ion F.
3 ordinances and State laws relatingto building construction, f��'lvs'
9 Total Fee O DMA Perm.
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection Pur se-p µ 01
SEE REVERSE FOR EXPLANATORY LANGUAGE
' Signa of App t •J O {r �:fl