HomeMy WebLinkAbout5683AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C. )
Policy No:86490 Company FAIRMONI' INS
❑ Certified copy is hereby furnished. 1/11 1
( Certified copy is filed with the c ',hty building.inspec-
LXJ tion department.
p
Date ��` Applicant✓
CERTIFICATE OF EXEMPTIONIFROM WORKERS'
(This section need not be corripletdd 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
)TICE TO APPLICANT: If, after making this Certificate of
smption, 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
Prof6ssions Code, and my license is in full force and effect.
u
License Number 283724 Lic. Class B1
Contractor PIERMARINI ENT -Date
® I am exempt under Sec.
B.&P.C. for this Signature
E - ILD DECLARATION
I hereby aff - that I am exempt from the Contractor's License
Law for �t a folio ing 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 Name
Lender's Add s
I certify that I ave read thi application and state that the
above infbrmat on is corre agree to comply with all County
ordinances d State la s relating to building construction,
and h y authorizer esenlatives of this County to enter
tiTpvr t e above -men 'o ed property for inspection purposes.
Signature ofApplicant or Agent Date
J
COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING
FOR APPLICANT TO FILL IN ADDRESS 2672 WAGON TRAIN LANE
BUILDING ADDRESS 2672 WAGON TRAIN LANE DIAMOND BAR, CA.
CITY 'DIAMOND BAR ZIP 91765 LOCALITY
NO. OF BLDGS. NEAREST
SIZE OF LOT NOW ON LOT CROSS ST PnC'KV TRATT, PT) _
Off! FRANK MURO
ADDRESS 2562 CASTLE R
CITY DTAMC)ND BAR -
ARCHITECT
ENGINEER IERMARINI/JOHN
ADDRESS 770 PINEFALLS
ADDRESS
SQ. FT.
SIZE
DESCRIPTION OF
15 OF
USE OF
EXISTING BLDG,
ADDRESS
ASSESSOR
LOT NO. 82 MAP BOOK
No. 595-1307 USE ZONE
RD
HW 11111 �
PTERMARTNT ENT-
TEL.
No. 594-480
770 PINEFALIS No. 283724
WALNUT
C ASS
B1_
NO. OF
STORIES
NO. OF
FAMILIES
CHECK
ONE
WORK
NEW
ADD
NING WALLS ( '
lr
20 ry 4
fo 04
ALTER
REPAIR
DEMOL
-a
MOVING TEL.
CONTRACTOR NO.
P.
SIDE
P. L.
Investigation Fee
PARCEL
e)—?>,3
DISTRICT I GROUP I TYPE JFIRE PROCESSED BY
CONST. ZONE
�cle"
STATISTICAL CLASSIFICATION APT. 031,00.
CLASS NO. DWELL. UNITS
SEWER MAP
BK. PG. I VALIDATION
VALUATION
$ 4 .-
$
FINAL
DATE I
By AL aw
El
0, 0 A
{ 0O
YARD I HWY 11 ono 1 .twin nwi.
PROP. LINE WIDTH r� A
i
f� C LDMA Ref. #
Permit Fee
Issuance Fee ��j LDMA P/C # 0
R
Total Fee �0, LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE
AN!
7 0 B Y P.,I ; llI
6E SPf C'i'4 P'S NOTES
Tw
Returned
Approved
i:i0p
No' Own,
t,pF'Q�VrAi".�
m �tr gwAred
._._.__._._
Y�rs
Psgsa
Fjoto Received ,
or A¢3gxfdiV4,d
wr)ler C e. r1,fICUIe
t{rarlllh Cie.partmerat
Fire Department
Grading
Pe lesiricin Protection
r
..
gF n(e) ((anopy)
(ial In pecliorl
(Lone.) 0vA,i,onry) (WPIding)
-
lul Dmin Ili,,
---------------
Pof hlng
�. . �
..... ,._._,.,.. .._.__.� ._.,..._..___ ._... .-� ._.T_..
""-" __. _.. ..... __.....„._..�..
fati,,ars 4 a9is; (bl,9ie,..�.-t.d
,�,
€l �'3 a:,9G � SErj&7, f9t 2i Y&k
r
Locahon
xa c i ' Yards)
-.---- --_--_
f ounda6rins
Slat
Frame
Mercy In ulotion
Lath/Drywall ....
Interior
. ..—___..— ....... ._�
Lath Exterior
Ho / Nhimber _
C rrt c i & Posted
FIn,I
Enter on Front
..... ... _----- -
---- _--------
OWN FR-131Jlg,DF,1t DECi.ARA HON
I here>by afflrm ihol I am exempt tron, the Contractor's
License Law for the following reason (Sec. 7031 5)
Business and ProJ+ssiosis Code: , l ns crty or aunty which
requires a.,permil to constrtact, alter, imp➢'rra'c, itemolzsb,
Or a"(.p(i iY' art )' Stra Ctti r'a', prior to it,t Lc.Srf i.ila cC', also r ogvirev
the applicani ter such pwrmit tmfile a sii;ried shit-ownt
thin he is licensedpursuant to the provisions of the Con.
tractor's License I'Jit j(.;hapter 9)(c'oirimercririq u'itl, SVC,
tirrn 7000) of Oivisiou 3 of the Busiue,ss and Irrnfrss OF'S
Code) or that he is e.vempt thcrnfrom and the basis for the
alleged exemption. Any violation of Section 7031 5 by
a Pit' applicant fill' a perntlt suhiects the applicant to r cioil
penalty' of not morc thafi five hundred dollars (850 )),)r
1, as owner of the property, or my employees with
wages as their sole compensation, will do the wort and
the> structure is not Intended oroffered for sale (Set. 7044)
fdiisines.s and; Professions Code, 7he Contractor's l,il ense
Lau, aloes not apply to all atelier of property whir huil,is
or imProvcs thereon, and who does sac% atarr-9z biart.sel/or
through his otrn eeiploYee.s, pror,idvd that sn,-b it
pronemevts are riot intended or offered hr sale, -
however, the hu1✓(lin,r, or improvement is sold u'itliira one
tear of completion, the ou.'ner-bailder will haze the
Borden of proviei;r that he did not build or improve for
the purpose of vale),
as owner of the plope rty am exclusively ly con rna
tiny with licenseo contractor., to construct thn prul d :Sec.
7044) llasiiiess and Professions Coder The Coutruc.`ns-'s
License hair toes not apply to a*n owner o/ / ropei-ti u,bo
guilds or improves thereon, and wlw contracts for s:ich
projects tt'ith a co^ritraeters(sf li,,errscd p*m-sac at to ttic,
{,Cm) trac tor'',s license l,aid'),
I_I I am exempt undei Sec, 0 Ffi'.C. for this
reason— -- ___._. __. ..... _._,..,__....... __
Date ---- ---.— __... Owner _.
