HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (84) ._..._._.._.__.�. _ .._ ...._....__._._...----_--.......__-- -.._.
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WORKERS'COMPENSATION DECIARRTION � � � ' �' � - � � � - �
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i hereby affirm that i hove a certificate of consenf�o self qp�p�fCqTI�ON FO�� BU_IL�DIN�G��PERNIIT �
insure,or a certificate of Workers'Compens6iion Insurance,
or o certified copy ihereof(Sec.3800,Lab.C.) COUNTY OF LOS.ANGEL�S � BUILDING AND SAFETY -
P❑olicyNo. �� Company ��)iLh'[c�7T�ns� �
Certified copy is hereby furnished. , FOR APPLICANT TO FILL IN BUILDING ���C-
ADDRESS � �i3� �yy . .
� Certified copy is filed with ihe rounry buildinq inspeo- � BUiLDWG ` � � � �
tion department. ' . i AD�RE55 � �
/-� »/ �i��� / �.-
Date V^l�"a(� Applicant /�-� '��-T'�'��r/ CITY ZiP � LOCALITV
CEFF7IFICATE OF EXEMPTION�FROM VVORKERS' p NO.OF BLDGS. �,.. NEARE57 �
� COMPENSATION INSURANCE 5¢e OF�Oi �.}~ e NOW ON LOT .4j_� CRO55 ST.
(This seciion need not be complefed if Ihe permit is for one .4SSESSOR .
hundred dollars($100)or less.J TRACT BLOCK LOT NO. Mp,p gOOK PAGE PARCEL
� TE" USE ZONE MAP
I certify that in ihe perforreiqncs of the work�for which�this OWNER � NO. �„ � [ �� '� _ }
permif is issued,I sholi not employ any person in any monner �7 p+ e� �/p SPECIA� !� � �
so as to be<ome subject to Ihe Workers'Compensation Laws. A�OftESS� ,}� �- \ �lY a CONDIilONS i'�
.Ddte Applicant � Ciiv���j�� . EFI' . ZIP �7� �
NOTICE TO�APPIICANT: If, ofter making ihis Certificate of ARCHITEC70R ,! (' q•(r�7EL.7.iP /� DISTRIC7 GROUP TYPE FIRE PROCESSEDBY �
ENGINEER C ���J - � �I u O. ��a pJ� - - a"
�Exemption, you shouid become subject to the Workars' f, �!� �t CON � ZO V
Compensation provisions of ihe Labor Cade,you must forth- A�DRESSO , .r '`�r'�'Z"3 t � �
i�f• W
wiTh comply with such provisions or ihis permit shall be �' tE� y � � � wai
deemed revoked. " STATISTICAL,CLASSIF A ON APT. C NDO. �
�CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION �i�. CLn55 NO. �� DwEu.UNI75
I hereby affirm that i am Iicensed under provisions of Chapter 9 qooRE55 NO.
, (commencing with$ection 7000J of Division 3 of ihe Business and .. , ��� SEWER MAP
, ,Professions Code,and my�icense is in fuil force and effecL CiTv CL45S YALIDATION
' - � ' - ... BK. PG.
�-y �.� SQ.Fi. /� NO.OF �� NO.OF CHECK
License Number'6��Q� Lic.Class SIZE .'�y �Yr STORIES FAMILIES 7a� ONE c_��.`�[.C FI
J� � � / � VALUATION
ContraCfor� Q�ST•�4�•Dpfe ��3�i DESCRIPTION OF WORK NE'N s�„ , i a c c o_J' �
�I om exempf unc�er$ec. � ,�� C'� �/�. ��' ADD � V
,,�TER ❑ I 1.G.7 2 3
B.&P.C.for this reason�'.�,' ._ �� P J'�i REPAIR ; -
- USE OF � �Z S r'r)'�"� e �.�: /l.G J�
DEMOL
Doie: EXISTiNG BIOG. ° ❑
Signa}ure ' � APPUCANT�„ . rEL��p FINAL � �.C�:-�5
OWNER-BUILDERDECLARATION PRINT ' '\ ���i No.'7�'�" A(��
1 hereby affirm that I am exempt from the Conirador's License ����„� �"�"'yt��"' c� . � ��•� DATE ���j� ,_��4�9�; �
law for�he following reason (Section 7031.5, Business and ADDRESS �ii1� �`.nt" FIN , - �
Professions[ode): PRESENT gY �y A-c c w j� .
� I, as awner of ihe property, or my employees wifh ADDR 55 � � e�: �C,��
wages as iheir sole compensation,will do ihe work pnd
the structure is not inrended or offered for sale(Section �OCAiITY ;;� : - �,_
70G4,Business and Professions Code). . MOViNG 7EL �1�'�i,""-Pi l�" '
� CONTRAfTOR NQ �%G-2.�H:�� �
I,as owner of the property,om exdusively coniracting ��
with licensed controctors to construct the project(Sec- qDDRE55 �' o x a e e'I
tion 7044,Business and Professions Code). �� . ,
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDWG AGENCY � � ' SET BACK �ARO HWV pROR LWE- WIDTH � � J 4�j ���
I hereby affirm lhat there is a consfruciion lending agency for � FRONT �
-the performance of�he work for whith this permit is issued € p.L. , °-���L.,C',,�:,� _
(Sec 3097,Civ.C.). F SIDE "'
� P.L
Lender's Name j P { `'J"' '�y��'v
� ' " " � P.C.fee$ �"$ Permrt Fee f.r�(.�t S'o LDMA Ref.N
- Lender's Address
I certify that I have read this applimtion and state lhat the '� ��(p�� Issuance Fee '�( . V LDMA PiC N '
¢ above information is correct.I agree ro comply with all County � Inveviga�ion Pee
ordinances and State laws relating to 6uilding<onsiru<tion, Totol Fee �{ a � -LDMA Perm.# -
� and hereby authorize represen�atives of this County io enter _
upon the above-meMioned property for inspe<tion purposes. : ��. ��� �(�� �f��.r,. -
�J ,)�1.5
�l_�_�!� 4 �� �j�3�� SEE REVERSE FOR EXPLANATORY LANGUAG '.'
-. Signalure of Applicant or Agent Date � -
��
./
.,r<..K.sv. '/
�
'� 0�4'1F,R-BUILDGA UHCLARAI'[ON
PLANS TO APPLICANT l INSPECTOR'S NOTES �
.. I hereby affirm that I am exemp�from�he CoMroctor's
To: Relurned � �1 � License Law for the following reasan. (Sec. 7031.5)
Approved , �y . , 73r�srness and Professinns Code:Axy citP ur cou�ty wln'cfi
No. �afe No. - Date � - ��'� requires u permit tn construrt,ulter,imprnve,demnlith,
or repuirany structure,��rior to its usu¢nce,aLso reqaires
tbe applicun[fnr s�ecb permit tn file a signed statement
tb�t!e is 8renseJqar.rs�u¢nt to tbe provisinns of tbe Gin-
. . traa�tor'.s I,rcensc Luu(Chapter l/(commencing witl�Sec-
tinn 70UD/f LNcision 3 r�the Businass anJ Pro�ession.c
LbdaJ nr tba[fic is exempt iherefrnm ond tbe bdsufor the
. alfeqed zeemptiox.Any��inl�tinn of Seclrow 70)7.5 bt'
Required Dafe Recelved un y n/��licunt fnr u permit subjects tl e applicunt an u clve!
Approvnls or Approved . /�enult}�of nni mnrc�tFiars fiae buadred dollarr(JSOOJ.f:
Ves No
. ❑ I,as owner of the property,or my employees with
Woter Certificate � .. . wages as their sole compensation,will do the work,and
the struclure is not intended or offered for sale(Sec 7044)
Hephh Departmem. - Business und Professions Code:The Cnntracfor's Luense
!au�daes aox apply to an omnar f yrnpardy u•ho buiLds
Fire Department � - nr emproces LSereon,umd u�ba does suc5 u�ork 1 imselJ ar
througb 6u oac•re emplqyecs, proauled ebat sucfi im-
Grading - provemeats ure not istexded or <ffered/or sale. If,
' buwever,the hrorJdin,P nr improxremena is sold�ciabin one
Geological year q/romple6inre, tbe awxes-builler urzll bur:e the
barden of frox�ing tbat 1 e did not buifd nr imfirnve jor
Pedeslrian Protection . tbe purJiose nf sule).
�Fence)(ConopyJ C I,asowneroftheproperty,amexdusivelycontra<-
ting with licensed contractors to constr�ct rhe prolecr(Sec. "
Special Inspection 70441 Business and Pr<fassions CoJe: 7'Se C�+ntracinr's
lCanc.)(Mosonryl(Welding) Lieenm Lu:o daes not ayply to an owner<�rr<�r�>t,�u�h�
bvilds nr irreprne�es 11 ereon,anrl u�ho cnntructs for sucb
Lot Drainage - projects u.�itb �e rnntractnr/cJ licexsed pursuant tn tbe
Cox7ractnr's Licen.��e I.a:J.
Parking
;_I I am exempt under Sec. ,8.8P.C.for this
reoson
Date Owner
Approvals DaTe � specto 5 Signature
INSPECTOR'S NOTES
Locarion--� a / ; �tl �l�� . . . -...
(Setback 8 Yard jr
Foundarions §' '�' • /
�%~
Slab �1� ' '3 ,���L
L../'
Frame i �
. Energy Insulation
Lath/Drywall- � . , . .. . . . . . .
Interior
Lath—Ezterior
' �Jl
House Number�
Correct&Posted
Final—
Enter on From
ti
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