HomeMy Public PortalAbout9807 WINDSOR LN_Building__ WORKERS' COMPENSATION DECLARATION
r affirm that I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T
insusure,, or a certificate of Workers' Compensation Insurance,
or a ceErrtifie. co the�6��.Qfo(��.ec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NoP � — Company t1S &
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN / ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department.
Data+-2 3-8 9 APPIicG ' CIN T e m l e City ZIP 9 LOCALITY
8 7 0 0 0 NO OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION F M W RK Y SIZE OF LOT NOW ON LOT 0 CROSS ST.
COMPENSATION INSURANCE — ASSESSOR
(This section need not be completed if the permit is for one TRACT 4 313 6 BLOCK LOT NO. 10 -, MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) TEL. USE ZONE MAP
NO. 1, /
+7 C,
I certify that in the performance of the work for which this OWNER NO. —
permit is issued, I shall not employ any person in any manner ADDRESS 142 5 Melanie Ln SPECIAL a
so as to become subject to the Workers'Compensation Laws. CONDITIONS O
U
CITY Arcadia zip 91006
Date Applicant ARCHITECT ORTEL.
im
Same D STRICT I G OUP I TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. I CONST. ZONE
Exemption, you should become subject to the Workers' A
Compensation provisions of the Labor Code, you must forth- 1ADDRESS s• - i 13-
with
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIF CATION APT. CONDO. N
deemed revoked. CONTRACTOR Same NO. Z
LICENSED CONTRACTORS DECLARATION LIC. 2 6 5 8 6 4 CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 t ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business R LIC.
and Professions Code,and my license is in full force and effect. CITY CLASS B BK PG. VALIDATION
�� SI2 015 0 TORIES 2 AMIL1 ONE
OLIIES CHECK
License Number�b-�O �/%` Lic. Class � SIZE
VALUATION
ContracfdP Date ? : DESCRIPTION OF WORK NEW
❑I am exempt and Sec.
Residential attached 2car . ADD ❑ $
ALTER ❑
B.$P.C. for this reason Garage . REPAIR ❑ $ 1 01000
Date: USE OF v�
EXISTING BLD DEMOL ❑
Signature
OWNER-BUILDER DECLARATION PPLICANT(PRINT)George W i e g a n d N .286-3636o' FINAL
2_ _-L_, }
DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS 1425 Melanie Lane Arcadia FINAL
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT By
ElBUILDING
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.) MORNIEMM
O
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. p�,y
(Sec. 3097, Civ. C.). SIDE z A 4J n
BBH Mortgage P.L. 74ti
Lender's Name. Q""ooQp tom'— _J e
B LDMA Ref,
Y.C. Fee$• ,--}"t) Permit Fee # bP b
Lender's Address 8 8 W i l s h i r _ B e V P r l y Hi
,
-17.1 ,
1 certify that I have read this application and state that the Issuance Fee
3 above information is correct. I agree to comply with all County Investigation Fee Q
ordinances and State laws relating to building construction, Total Fee O ' Perm. #
and hereby authorize representatives of this County to enter
upon the above-mentioned propert r 1p ion purpo s
o SEE REVERSE FOR EXPLANATORY LANGUOC tom]
e o 0 0 o e
Signatur App ant o ' t 4J `� 2 Z8 O N