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HomeMy Public PortalAbout9813 WINDSOR LN_Building__ WORKERS' COMPENSATION DECLARATION hereby affirmrt that I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T insure, or a certificate of Workers' Compensation Insurance, or a cert!! led copy thereof(S�c. 380% Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo:�"oa�1 "4�9mp Hy uSF&G ElBUILDING Certified copy is hereby furnished. FOR APPLICANT TO F LL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING ��/ � tion department. ADDRESS Date ;22_a o A I i nt Cin' zip 91780 LOCALITY 4TrvT PP 87000 7 0 0 O NO.OF BLDGS. NEAREST yJ CERTIFICATE OF E 1EMPTIOI�F O O.R RS' 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 43136 BLOCK LOT,NO. 11 MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) WeStCO Land Inc. TE OWNER N6-3 6 3 6 USE ZONE OP i_ / A I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner ADD"2 5 Melanie Lane -e-,) CONDITIONS CL soas to become subject to the Workers'Compensation Laws. O CITYAr-cadia ZIP 91006 Date Applicant ARCHITECT OR TEL. tY NOTICE TO APPLICANT: If, after makingthis Certificate of Same DISTRICT ROUP TYPE FIRE PROCESSED BY ENGINEER NO. s/' P", � CONST. ZONE f. � Exemption, you should become subject to the Workers' ((�� Compensation provisions of the Labor Code, you must forth- ADDRESS rl) '- a with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFIFATION APT. CONDO. N deemed revoked. CONTRACTOR NO. [,��� (L LLZ LICENSED CONTRACTORS DECLARATION LIC. 265864 CLASS NO DWE . UNITS NO. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS LIC SEWER MAP (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. CITY CLASS B BK PG VALIDATION �__e SQ. ZE2 1 6 0 STORIES 2 FAMILIES O A OFCHECK 1 ONE License Number6J � Lic. Class VALUATION Contract Date DESCRIPTION OF WORK NEW ® $ ❑1 am exempt unde ec. Residential .attached 2ca 1.ADD ❑ , ALTER ❑ BAP.C. for this reason Garage. REPAIR ❑ S Date: USE OF Single family Res 707 3 ' U a d EXISTING BLDG. (9EMO1 ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT)Q e O r a Wi a and NO.286-3636 DATE �(Z � I hereby affirm that I am exempt from the Contractor's License gDDRES$4 2 5 Melanie Lane Arcadia FINAL X71 Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT BY El1,I, as owner of the e BUILDING p p rty, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY ► the structure is not intended or offered for sale(Section 7044, Business and Professions Code.) MOVING TEL. ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. F y (Sec. 3097, Civ. C.). SIDE :,36 P.L. .� Lender's Name S B H M 0;9 t o x o n e C] LD1171'A Ref. # qp 8383 Wilshire Beverly Hi l Fac. Fee$' Permit Fe . Lender's Address s, U c 1 certify that I have read this application and state that the Issuaficf3 Fee © LDMA P/C# � above information is correct.I agree to comply with all County Investigatlo F DD ordinances and State laws relating to building construction, ; Total Zee LDMA Perm. # and hereby authorize representatives of this County to nter -� upon the above-mentlo d ra erty for In Tion pu os s. sJ I•J t ) C3 W pJ Q �/ C7 SEE REVERSE FOR EXPLANAaRy>NGU/W .pj Sign a of pp1 ant r gent Da °'' "O y E'�