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HomeMy WebLinkAbout7178AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self APPLICAfIO'N FOR BUILDING PERMIT insure, or a certificate of Workers' Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. �om8panD J_ U Tndemn Certified copy is hereby furnished. Imo, Certified copy is filed with the county building inspec- tion department. Date 4-15-81 Applicant Arciero & Sons CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number 3 i 9 r; 9 5 Lic. Class B— 1 Contractor Arciero & Son�%ale 4-15-81 ® I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer acting in my professional capacity (Section 7051, Business and Professions Code). Lic. or Reg. No. _Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 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.). Lender's NameHomestead Savings & Loan Lender'sAddress1777 Murchison, Burlingam w I certify that I have read this application and state that the CA above information is correct. I agree to comply with all County aordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter aupon the above -mentioned property for inspection purposes. m d a Signature of Applicant or Agent Dote FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS LOCALITY CITY Diamond Bar ZIP NEAREST CROSS ST. NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL USE ZONE MAP TRACT. BLOCK LOT NO. NO. OWNER Arciero & .Sons N6598-1821 CONDITIONS DISTRICT GROUP FIRE PROCESSED BY ADDRESS 20001 E. Walnut Drive fl`E NST. ZONE CITY Walnut CA ZIP 917 H 9 11 STATISTICAL CLASSIFICATION APT. CONDO. ARCHITECT OR R J TEL. Marvi ck NO.9 7 9 - 7 6 6 5 ENGINEER . . CLASS NO. DWELL. UNITSmommommommmmmom ADDRESS 1 / bJU 5KyPar 1 l:1 . , 1rV111U TEL, CONTRACTOR Arciero & Sons NO. 98-1821 ADDRESS 20001 E. Walnut No. R232959 LIC. CITY Wa 1- SQ. FT. NO, OF tFAOMILIE . OF SIZE ti R n STORIES 2 DESCRIPTION OF WORK USE OF EXISTING BLDG. APPLICANT TEL. fPRINTI Arrni Arn R, grant~ NO. —1 CHECK ONE ADD ALTER ❑ REPAIR ❑ DEMOL ❑ BUILDING ADDRESS LOCALITY MOVING TEL, CONTRACTOR NO. ADDRESS REQUIRED HWY TOTAL SETBACK FROM EXIST. SET BACK YARD PROP. LINE WIDTH SIDE P.L. P.C. Fee $ .`-. - ,./ r _f',f I Permit Fee Fee Investigation Fee - Total Fee SEE REVERSE FOR EXPLANATORY LANGUAGE SEWER MAP BK. PG, VALUATION s159,040.00 FINAL DATE FINAL By VALIDATION %1 /,RA ir s <, e3 J 5280 a e 0 '25 _ I ) c3 0k '.5 g1 ©s