HomeMy WebLinkAbout0441WORKERS' COMPENSATION DECLARATION
I hereby affirm That I hove a certificate of consent to self
insure, or o certificate of Workers' Compensation Insurance,
or o certified cop Ill reof (Sec. 38 Lab. �`)
Policy Nc, [! Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
`�ti n department.
Date � 3 4 jv� Applicant
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.
Dote Applicant
idQTICf TO APPLICANT: If; after making this Certificate of
iemption, you should become subject to the Workers'
.ompensation 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 c J d Lic. Class
Contractor Date
/f[ 'tb% l `I 4> _� ' � :26
® I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that l 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 sole (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 Address
I certify that I have read this application and state that the
above "snformation is s+�rrect. I agree to comply with all County
ordinances and to l ws relating to building construction,
and het
ut o 1 representatives of this County to enter
o tve n)ioed property for inspection purposes.
Sign vre of Applicant Agent Date
APPLICATION FOR BUILDING PERMIT
j4
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS 21331 to 21349 Cold Springs
BUILDING ADDRESS 21331 to 21349 COLD SPRINGS LANE
-Lane
DIAMOND BAR, CA
CITY ZIP
LOCALITY Diamond Bar CA
SIZE OF LOT NOW ON LOTS 4
ST
CROSS ST. Diamond Bay' Blvd.
ASSESSOR
TRACT BLOCK LOT NO.
MAP BOOK PAGE
PARCEL
TEL
DIAMOND BAR INVESTORSN047 -19 0
USE ZONE MAP
OWNER
NO. 102-333
1301 DOVE ST. SUITE 470
SPECIAL
c— i
ADDRESS ,
CONDITIONS
BEACH, CA 92660
CITYNEWPORT ZIP
ARCHITECT OJT TEL ,I
ENGINEER t?NACAL ENGI '' ;RING NO.77`+-1 3
DISTRICT GROUP TYPE FIRE
PR ESSED BY
CONST, ZONE
ADDRESS 1900 E . LA PALMA AVE . , SUITE 202
j � �
, _ 1>
IEIM, CA 92803 TEL.
STATISTICAL CLASSIFICATION
APT, CONDO,
CONTRACTOPIIANO,
LIC.
CLASS NO. DWELL. UNITS
ADDRESS NO.
LIC.
SEWER MAP
CITY CLASS
BK. PG
VALIDATION
SQ. FT. NO. OF NO. OF CHECK
SIZE STORIES FAMILIES ONE
DESCRIPT€ON OF WORK RETAINING WALL NEW
vALUArION
ADD
ALTER ❑
REPAIR
$
USE OF DEMOL
EXISTING BLDG.
° o 9 1. 3 8
APPLICANT& E l ' l4 774-1763
FINALPRINT
I714No.
DATE
r
I
ADDRESS Same as Engineer
FINAL
l
PRE ENT
By
8 4�
LOCALITY
MOVING TEL.
CONTRACTOR NO.
nuvrcwo
�'!� 697,
REQUIRED
YARD
HWY
TOTAL SETBACK FROMJLLDMA
SET BACK
PROP. LINE
f i
FRONT
P.L.
SIDE
P.L.
i
P.C. Fee $
Permit Feo#
issuance Fee #Investigation
Fee
Toro! Fee . #
SEE REVERSE
FOR EXPLANATORY LANGUAGE