HomeMy Public PortalAbout9816 WINDSOR LN_Building__ I WORKERS' COMPENSATION DECLARATION
'Thereby affirm that I have certificate of consent to self
insure, APPLICATION or a certificate of Workers' Compensation Insurance,
or a certified copy thereof
(Sec 37 Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. r0 O al I Comp nyaLTTT C F&
BUILDING
ElCertified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS '00? �
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS p dd
Dat -23-89 APPlica 1Gr� CITY ZIP91 7RO LOCALITY
NO.OF BLDG5 NEARE
CERTIFICATE OF EXEMPTION FR15M ORS' SIZE OF LOT 87000 NOW ON LOT 0 CROSS ST.
COMPENSATION INSURANCEASSESSOR
(This section need not be completed if the permit is for one TRACT 4313 6 BLOCK LOT NO.14` i MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) OWNER W e s t c O Land Inc. No. 2 8 6-3 6 3 U 5 ZONE MAP /
I certify that in the performance of the work for which this NO. n
permit is issued, I shall not employ any person in any manner ADDRESS 14 2 5 Melanie lane eIAL� CONDITIONS n'
so as to become subject to the Workers'Compensation Laws. O
CITY Arcadia zip 91006
fy
Date Applicant ARCHITECT OR TEL. DIS RICT I GROUPTYPE FIRE PROCESSED BY 0
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE �
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS '� ' r S a-
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO, Z
Z
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 265864
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS B BK PG VALIDATION
p ` SQ. FT. NO. OF NO.OF CHECK
License Numbe&�,''-o ele Lic. Class SIZE STORIES 2 IFAMILIES I ONE
�b- �,�'Ys. � DESCRIPTION OF WORK Single Family NEW ® VALUATION
Contracto Date ADD ❑ $ ,
❑1 am exempt under Sec. Residential attached 2car
• ALTER ❑
BAP.C. for this reason REPAIR ❑ $ 00 Q
Date: EXISTIING BLDG. Single f ami 1 y r e s i cbEMOL ❑
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION
(PRINT)George W i e and No. 286-3636 Z--/L—g�
DATE
Ihereby affirm that I am exempt from the Contractor's License ADDREssl 4 2 5 Melanie e
Law for the following reason (Section 7031.5, Business and FINA�j
Professions Code): PRESENT By v
El
BUILDING
I, as owner of the property, 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.) v
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH r
I hereby affirm that there is a construction lending agency for FRONT 16
the performance of the work for which this permit is issued P.L. U
(Sec. 3097, Civ. C.). SIDE ,�
Lender's Name B B H M b r t g a g e P L. f ' ��� a . y l � '
B P.C. Fee$ Permit Fee t �DMef qp
X383 Wilshire Beverly Hill
� Lender's Addres 1� P/CSC—•i
C7 C7 O LDMA
� I certify that I have read this application and state that the Issuance Fee A10L.J
above information is correct. I agree to comply with all County Investigation 7
ordinances and State laws relating to building construction, Total Fee l LDMA Perm. #
and hereby authorize representatives of this County to enter ,
a upon the above-mentioned rope y for inspection pur o s. t-+ j '
o �� � �n SEE REVERSE FOR EXPLANATORY LANGUAG2 ° °_'
Sign a of A lica or ent e J `ri O J 6- OZA f 3