HomeMy WebLinkAbout03_23_1989 - 769 S NEWBURY WY � WORKERS'COMPENSATION DECLARATION . -� �� " ' ' � ' � � - - J�
I hereby affirm�ha�I have a certificote of Consenl lo,e�f ;- - - APPLICATION FOR BUILDI�NG PERMIT�
insure,or o certificafe of Workeri Compensation Inwrance, � L�
or a tertifled copy thereof(Sec.3800,tob.�C.) � ' � - COUNTY OF LOS ANGELES ' BUILDING AND SAFETY �
' Pol�cyNo. �$6�/�,� Company ��g��a��
� Certified topy is hereby fumished. FOR APPIICANT TO FILL IN BUItDING
ADDRESS
Certified copy is filed with tha[oonty building inSpeC- OUIIDING�
�iondeportmenr. � . . � ADDRESS '769 S. .Newbury Way - - 769 S. Newbury Way
Date 5-1-89 qpp���p��BTflAtdle3�Cd� IRC � cinDiamond Bar Aills Zip 91765 � - Diamond Bar Hills
toC.nutt
CERTIFICATE OF EXEMPTION fROM WORKERS' �I - NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE � � SIZE OF LOT NOW ON LO7 CROSS ST. - ' � � '
(This zecfion need nof be tomplefed if the permit is for one �- TRAC4z56k. � eL� ��T ND (2 ASSESSOR � .
hundred dollars(5100)or lesi.) MAP BOOK PAGE PARCEL
owNeQ Bramalea CA, Inc No. 850-1001 �� "'''P ^� q
1 certify thot in the performonce of the work for which this �- ��� r10. 1 �' J 1
permit is issved,I sholl not employ any person in ony monner � saEpal �
so as to be[ome su6je[I fo the Workeri Compensalion Laws. ADDRE55 1 1 $te jQ CONDITIONS - �
O]
ary nP v:
Dafe- � AppllConl ' ARCHIRGT(�Q TEL.
NOT�CE TO APPIICANT: If, ofter making�this Ce�tificofa of � �y g r,o553-9100 DISTRICT GROUP TYPE fIRE PROCESSED 6Y p
ENGiNEER assenian La ORl
�emplion,�you should bemme sub�ect 10�the Workers' - - CONST. ZONE �'
mpensaiion provisions of tha Lobor Code,yo�must forrh• lO R-3 VN IV w
ADDRE55
with comply with such provisions or this permif shall be _ _ , _ TE� d�
deemed revoked. - CONTitACTOR N� � STATISTICAL CL4SSIFICATION APt. CONDO. �
- LICENSEO CONTRACTORS DECLARATION f9d '�' I Z
LIC� C1A55 NO. DWELL.UNITS .
I heteby ofiirm that I am licenaed under provisions of Chopter 9 ADDRE55 �$ r,o. 409610
(commencing�wilb$eclion 7000)of Division 3 of Ihe 8usiness and ��� SEWER NulP
Professions Code,and my Iicense is in foll force ond effecL - GITV - � Cu55 BK � .- . VALIDATION
S�.fT. NO.OF NO.OF CHECK
LitenseNomber ������e liaClass$ SIZE STORIES FAMILIES - ONE -
� �' � VAWATION
DFSCRIPT�ONOF WORK � N� �
ControUor B amal � A, ri naje 7���—RQ �� ADD � s 5�C 5� �6 G�x��
�I am exempt onder Sec. - . p�7�R� � � �9• • •2�
B.BP.C.ior this reoson P�.BR 25 =
REPAIR 4 1-&5 9 �
DOIB: � � USE OF � c
�'-�' EXISTING BLDG. DEMOL ❑
-Stanalvre� - � APPLICANT - TEL ��e�1� G.J%v
FINALn
vOWNER-BUILDER�ECLARATION PRINT �� — - DATE L-�I� f
I hereby affirm Ihat I am exempt from the Comrattor's License - � �[� � �=�C
Law for ihe following reason(Section 7031.5,8usiness and /•DDaESS FINAL
Professions Code): - pgE ENT -By .
� BUItDING
I, as owner of the property, or my employees with qooeE55
wages as their sole compensalion,will do the work and � '�r
) the stroctore is nm imended or offered for sele(Section LOCAUN � .i� -
7044,Bosinees and Professions Code). -- � pnOvirlG . TEI. �.(�2�9 a
� I,os owner of the properfy,am axclvsively mnfrociing CONiRACTOR NO. . � �
with litensed contmcton to conslruct the project(Seo- ADDRESS� -- .. � . +� #•� • • • �
tion 70d4,Business and ProfeSsions Coda). ��'
� - CONSTRUCTION IEN�ING AGENCY � SE�sACK YARD HWY TOTAP OP.IINE wiDTH ! � � �7� 4'O�
I hereby offirm�hot the�e is a consfrucfion lending agency for FRONT � � i
the performance of the work for which this permit is issued p.�, _ i,�''r,• -� .'��� • �7� 4,l,U�
�Sec.3097,Civ.C.). SiDE � � � '
lender's Nome ToY'onto Dominion Bank P��� ,� ! ` 0 4.1 3—8 9
�/ LDMA Ref.M
lBnder's Addrefs $an- F=an�yarn�� -CA � P�C Fee S �1 A�� Permit Fee Q � , .
1 certify that 1 have roed this opp�itation and state that the __ _ issuo�ce Fee 0�� �DMA P/C N '
obove informa�ion is corcect.I agrea to tomply with all County Invesiigotion Fee J�� �
ordinances and State Iaws relattng to building tonstruttion, Total Fee .CJ�� LDMA Pnm.N �
ond hereby aulhorize representatives af Ihis County to enter� -
u/pon7 fhe obova-meMioned�Property for inspec�ion purposes. LDm r7 ��� �ry1�, �
/J�'�'�'GG!/�`2���i�id�'� �L3 6� SEE REVERSE FOR EXPIANATONY UNGUAGE T�S
� SignaNro of Applimnl o�Agent pote - . .
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