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HomeMy Public PortalAbout9822 WINDSOR LN_Building__ WORKERS' COMPENSATION DECLARATION Hereby nffcdthat I havecertificate of consent to self r ' A P P L I CATION FOR BUILDING P E RM I T insure, or a certificate of Workers' Compensation Insurance, - - or a certified copy thereof(Sec, 3800, Lab:C.) 1L COUNTY OF LOS ANGELES BUILDING AND SAFETY �a,,'�U S F&.G . 'Policy No. 0�O amp ny ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRIESS Certified copy is filed with the county building inspec- BUILDING �/�Z %NC` tion department.. ADDRESS ,See L,¢jv `moi Date 4—2 3—8 9 gppl; ��.�;2� CITY Temple' -Cityz�1 LOCALITY NO.OF BLDGS. NEAREST r� CERTIFICATE OF EXEMPTIO M RKE S' SIZE OF LOT NOW ON LOT 0 CROSS ST. (/tl�i�c 'COMPENSATION I URANC 4 313 6 ASSESSOR (This section need not be completed if The permit is for one ' TRACT BLOCK LO-TAAIO,; MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL• USE ZONE MAP �{� OWNER WeS NO. USE that in-the performance of the work for which this SPE '"[ 1425 Melanie Lane SPECIAL- ?• permit is issued, I shall-not employ any person in any manner ' •- • ADDRESS — a CONDITIONS so as to•become,subject to the Workers'Compensation Laws:. O CITY Arcadia zip 91006 v Date Applicant ARCHITECT OR TEL. DISTRICT GROUP I TYPE FIRE PROCESSED BY Ix NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER. . Same NO. -� CONST. i 1 Z NE i • r) Exemption, -you, should become •subject t the,Workers' ( / (� p, Compensation revisions of the Labor Code, you must forth- ADDRESS J v F� "� with comply with such provisions:or this permit shall be TEL. STATISTICAL C SIFICATION APT. CONDO. v7 deemed revpked., CONTRACTOR Same NO. Z LICENSED CONTRACTORS DECLARATION ADDRESS NO. 265864 CLASS NO.� DWELL. UNITS — I hereby affirm that I'am licensed under provisions of Chapter 9 ; . ' . .. SEWER MAP ' (commencing with Section.7000).of Division 3 of the,Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS B BK. PG. VALIDATION �` SQ. FT NO OF NO.OF CHECK License.Numbe. Lic. Class SIZE 2.3 0 0 STORIES,. 2 FAMILIES 1 ONE VALUATION .. a, '- DESCRIPTION OF WORK S'1 n 1 e NEW $ Contractor 11-1:1162. •�pte ADD ❑ :;-s -. • Reside•nt.'ial attached 2car pill. --• ••� ❑I am exempt,under Sec. _ ALTER ❑ •• B.&P.C. for this reason Garage, -. . - $ REPAIR ❑ USE OF ©D V e , date �' EXISTING BLDG. DEMOL Signature APPLICANT TEC . g (PRTNT)G.e o r g e W i,e g o n d - No,• 2 8 6-3 6 3 6 '•FINAL OWNER-BUILDER DECLARATION 'DATEi I hereby affirm that I am exempt from the Contractor's License ADDRE�2 5 m e t a n i e lane Ar c a;d i a • Law for the following reason (Section 7031.5, Business'and• FINAL„ Professions Code): PRESENT By BUILDING ❑ I, as ownei of the property, or myemployees with ADDRESS wages as their sole compensation,will do the work and ACCT a- �, LOCALITY ; { i e T t the structure is.not intended or offered for sale(Section - •7044, Business and Professions,Code.). MOVINGTEL. '❑ I,as owner of the property,am,exclusively contracting • CONTRACTOR NO. O '\ 3307 177.70 / •t , with licensed contractors to construct.the project•(Sec- gDDRESS tion 7044, Business and Professions Code.) ;• JI A��TvA - 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 ;j A7 0080.25 the performance of the work for which this'permit.is issued P:L. (Sec. 3097, Civ. C.). SIDE •. ' I 2 ITEMS P.L. Lender's Name,BBH Mort��P i LDMA Ref. # TOTAL 111- .95 P.C. Fee (33.93. Wi •l i;hi're Beverly $ Permit Fee .Lender's Address •H7.1� CHECK '_ � 11$70'�5 , 0 I certify that I have read this application and state that the Issuance Fee ®•-rd LDMA P/C# , CHANGE ' ■.I0 above information is correct.I agree to comply with all County Investigation e- /y'1 Q� ordinances and State laws relating to building construction, Total Fee / OR LDMA Perm. # c and hereby authorize representatives of this County to ent' ���—QQ�1 V� 1/y upon th above-mentioned property for ins ectiori pu os SEE REVERSE FOR EXPLANATORY LANGUAGE 41 1 A� pa° Sign a of/ PIIcp 1 0 -ent. D e