HomeMy Public PortalAbout9810 WINDSOR LN_Building__ WORKERS' COMPENSATION DECLARATION
insttte herebor a certif cane of rkWorkers' Compensation on a certificate of eInnt to self surance, APPLICATION FOR BUILDING PERMIT
or alcertifie ojy thereof.(Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic�- "fs _�Co'mp&y USF&G
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDING Q )�
tion department. ADDRESS �!/ vc/�� -/� /233
Date A— 3-89 Applic %h-�1 CITYT e m 1 e ZIP 780 LOCALITY ! a
NO. OF BLDGS. NEAREST
MP /
CERTIFICATE OF EXETIO�FWC9'�'KER�- SIZEOF LOT 8 7 0 0 0 NOW ON LOT 0 CROSS ST.yGp�t�� •r5
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT43 13 6 BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) TEL' USE ZONE MAP
OWNERWestco Land Inc . NO. 286-3636 No. f •*�
I certify that in the performance of the work for which this SPECIAL O
permit is issued, I shall not employ any person in any manner ADDRESS 1425 Melanie La e � CONDITIONS 33137 87 .
so as to become subject to the Workers'Compensation Laws.
CITY ZIP 2 ITEMS U
Date Applicant ARCHITECT OR TEL. �
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Same NO DISTRICT GROUP TYPE Flf -r� PROCESSED BMPI i •Q(pl
Exemption, you should become subject to the Workers' 1 Z lUl .R+
Compensation provisions of the Labor Code, you must forth- ADDRESS � CONST.
,r� — 101. .ti
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION r CONDO.
deemed revoked. CONTRACTOR NO. `
LICENSED CONTRACTORS DECLARATION LIC. CLASS N�DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 265864
SEWER MAP
(commencing with Section 7000)of Division 3 of the Business CITY LIC.CLASS - B `0�—�r��' IS/
and Professions Code,and my license is in full force and effect. BK PG. f� ALIDAp ON qtr G. c-
G��f SQ. FT. NO. OF NO. OF CHECK41113.`�— FII i 7•IJ.r
License Numbers Lic. Class SIZE STORIES FAMILIES ONE
��/
��%%,.••_��.; VALUATION
Contractoo v to DESCRIPTION OF WORK Single family NEW U
ADD 1:1 $
❑ ►
lomexemptunde'ec. Resiidential attached 2ca •
ALTER ❑
B.&P.C. for this reason
USE OF
REPAIR ❑ $��a , p p C1
Date: EXISTING BLDG. Single family R e s i DEMOL ❑
Signature APPLICANT TEL. FINAL g`
W i e a — DAT
OWNER-BUILDER DECLARATION (PRINT) George E
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT By �r
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- PDD O
tion 7044, Business and Professions Code.)
REQUIRED CONSTRUCTION LENDING AGENCY BACK
YARD HWY TOTAPROP.SETBALINEFROM WIDTH
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097, Civ. C.).BBH Mortgage Lender's Name LDMA Ref. #8383 Wilshire Beverly Hill $ . Permit Fee
� Lender's Address ,
I certify that I have read this application and state that the Issuance Fee �� LDMA P/C#
3 above information is correct. I agree to comply with all CountyInvestigation Fee
ordinances and State laws relating to building construction, A(or Fee /Total r LDMA Perm. #
i and hereby authorize representatives of this County to enter
upon the bove-mentioned props t or insp tion p pos
S /
o SEE REVERSE FOR EX 'ANGUAGE
Signa of Annitcant A e