HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (3) WORKERS'COMPENSATION DECLARATION � �
I hereby affirm ihof I have a certifimte of consent fo self APPLIC�Tt�N FOR BUILDINC9 PERIV�IT
insure,or a certifimte of Workers'Compensation Insurance, �
or a certiFied copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BU1Ld1NG AND SAFETY' ��
Policy� '� .� ompany .�l����7'-`. t"G%i.i!� . . .
BUILDING
❑�y� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADORESSr{z<' ')i�� (t 'J F:� �'r?- � -��-
� ;{' Certified co is filed with ihe count buildin ns ec- gUILDING �L"�*' ;"�.s ��a �'?� �L.�j,: - -
`r1 PY Y 9� P ADDRE55 '+f�.��� f.:{�Jf:4`j. •
J.
� tion depariment. . u� 4 �
Dd1���=Applicant ���"�''%--- �.�.:.j+'"r+��v CITV �'!��i�f�\.}IJ �°��'r:�ZIP LOCALI'Y .�,
NO.OF BLDGS. NEARESi
CERTIPICATE OF EXEM�ON FROM WORKERS' SIZE OF l07 NOw ON�oT Ce055 ST. I.-�-i'� � !� F�''�r�
COMPENSATION INSURANCE ASSESSOR
(This section need not be tompleted i4 ihe permit is for one TRACT 6LOCK LOT NO. Mqp gOOK PAGE PARCEL
h�ndred dollars($100)or less.) ? TEL.
OWNER '-�f'J�'� Li'[:--C..j� NO. USEZONE N✓�P �/I� � ,r
Z e�-`'-
I certify ihat in ihe performance of the work for which this �-" Ail SPEGIAL }
permit is issued,I shall not employ any person in qny manner ADDRE55 ��7"i�. *"� j CONDITIONS a-
so as to betome su6ject to the Workers'Compensation Laws. Q
CITY ZiP U
Dpte Applicanf ARCHITECT OR TEL �ISTRIC7 GROUP TVPE FIRE PROCESSE�BY �
NOTICE TO APPLICANT: If, afrer making fhis Certificote of ENGINEER NO. CONST. ' ZONE �
Exempiion, you should become subject to 1he Workers' P (]
Compensation provisions of the Labor Code,you must forih- AD�RESS C� '�- �
with cOmply wit'n suCh provisions or this permit shall be ' F m TEL ; � �r,-. STATISTICALClAS FICATION�, APT. NDO. N
deemedrevoked. CONTRACTOR � -;::"'�: -�°'��?%��LMO. �r?J =P�-�_', Z
LICENSED CONTRACTORS DECIARATION qD�RE55 `!j i f�*-�C' +1�ry�IF-' NO�.�'J Y ;�'(g� CLASS NO. ��� DWELL 11NIT5
I hereby affirm that I am licensed under provisions of Chapter 9 - "� ,
commencin with Section 7000 of Division 3 of fhe Business � � �'-� � LIC. SEWER MAP
( s ) a1v =.fl;�.j�r.: ; �,,V� ,k.l��v£.i}: anss �.�.
and Professions Code,and my license is in full force and effect. � gK pG VALIDATION
�./ r ' SQ.Ff.� NO.OF ` NO.OF � CHECK
License Num6er-�.����✓ /.�� Lic Class (-.. A,�L SIZE � STORIES FAMILIES ONE VALUATION
,.'_-ry "T� � r DESCR1P710N OF WORK {�'�.�i�-�f�+�f-- '� NEW �� )y�
a .- . ....' , Y
Contractort-.i.,-Y'i,:1-�G i..�(1r�.-�� Date - "". �� ._ 7•.. . " f. r S !<lE/?' ���`�
/ ADD � ► J 9 y
❑I am exempt under Sec. %«-5%+�L'�-. L'`l'�i= ����=r�7 f �1 =.�-�
�� :�-V . fa � ALTER LJ �
B.&P.C.For ihis reason !�--2:�4- • i/"C�P��- REPAIR ❑ i �* e'' ` "'��
� Date: USE OF
�{� �{,y EXISTING BLDG. DEMOI❑ � p _�`'�
.�/_f,,:d<.��✓ !„✓�Z,"�rL''✓'�� APPLICANT , i i�
Signofu�e- - %' ' i? TEL Ck�.'C.F'�- FINAL /� �
� OWNER-BUILDER DECIARATION (PRiNT).�:,.,5�??*r ��j_,�„o„'t�J NO. P`t�-• -r'��` OATE ^�Z-GO � �w - �"�''"'
I hereby affirm thal I am exempt from the Contracror's License ADDRE55 s'��FS} r�F--��,{�('?�'�`'��'LL3 �"�7L�� � � 1 E c r-��
Law for the-following reason(Section 7031.5, Business and PINAL
Professions Code): PRESENT By
❑ I, ps owner of ihe ro ert or m em lo ees with BUILDING
P P Y• Y P Y ADDRE55
wages as iheir sole compensation,will do the work and �OCALITv ,
the sfructure is not intended or offered for sale(Section
7044,Business ond Professions Code.) MOVING 7EL.
I,as owner of the properiy,pm exdusively coniracting
CONTRACTOR NO.
with licensed contractors to construct the projed(Seo- =:..`.'Q i1 N.
tion 7044,8�siness and Professions Code.) ADDRESS
REQUIRED TOTAL SETBACK FROM EXIST. Y;a _ - c .
CONSTRUCTION LENDING AGENCY ser aqcK �ARD Hwv ppOv.uNE wiDTH �
I here6y affirm that ihere is a consiruction lending ogency for FRONT � m�5`���%
ihe performance of the work for which this permit is issued P.l. �
(SeC.3097,Civ.C.). SIDE � - --
P.L. � �_,: !��.
Lende(s Name �)�- �J �" LpMA Re4.q I L C�'�-�3�,i �
3` P.G Fee 5 xy .� Perm��Fee e71.�"�"� ►
Lender's Address C
° I certify that I have read this application and stafe that ihe Issuance Fee i� =`�� L�MA P/C p
8 above information is correct.I agree to comply wi�h all County investigarion Fee �
Q ordinances and State laws relating to building consiruction, Tmal Fee �� - �� . LDMA Pe.m.q
� and heJ eby authorize representatives of this County ta enter _
upon,Xhe above-mentioned property far inspecfion purposes.
� ,.��v%�''�2��-1.����r�'i;{;€�_.� (r^"'yI~ "�J' SEE REVERSE FOR E%PIANATORY LANGUAGE .
�� Signature of Applimnt or Agent Date�
_ —,-_.�,'.,� ___�_,,.m,.i��...,a.,e...e..�._��_.� .-.�.....v.....ev_—�.mrss;.u,..�.n�-q�.-=�..�a��,. - � z-.
r
:..��Vm,ss,._..�..�,�.:� Fi6.:dS 7C�APPLICRi�3T.�.�•,. ...�-<...o..-a__ifdSP'ECYQFB'�e�iLzYcS. .. .�:Y . -- - �,•--.__ Ci l� A SUII�eR DF�SARAFf'O�1
�___,..�...e_....�.:_��.,._.-=.�w.-p-._.-T..._-s.a-�..._�_ -.o...�....�_..�._.,..�.�_.. .,..._. .,, ..'......_._._... i it8'eb'y�Bifritn t�.-E...:n�aerrzpt 6rctr,:h^c Co!1.C8CYOP';,
i�ro• � ReE�•n�d License Law fc F... :oiiawing�reason. (Sec. 1031.5;
Approrad ��_�_ - --.- , --a. �3�sine;s anG Professions Code:A.7y c,1y o:coUr..ry v:hich
�?4��3ate No. _U89e ��_ �. �&s7W;o-7s s p�iriir r�construcl,alYcr,impr�v�,da;:o!!S$,
t Ot;E�P'i81I3tt`f SfI„C2UT8o b1f107 FO I PS 13EU37iCG',d;'30;By'SlflBS
I ; ti;U apyl;san.,to�auc;permG tc tile a ai{Jft6C?Se"&i2uTi2Af
��_� � __ _____���.-. . __._. . ._._,..r . thaShe:::iicerssedpursuanEfofhe�ros•rriorscttHeCon-
.. �� . A�^T�_�� .� 'rsclor'sL�csnsaLew(Crapt�r31!4oenmer.cingwithSec
�icn:GG61 ct�ivisicr 3��fhe BUsines,and Pro'essions
_ � I ' � Core;or fi�af he is exempt zYeref!cm er.d Phe beais iar
4�,_,�_.....T.. .a.� - --- --�---.�.. -_..._ thc3;%s�etl�xem;.fio,,.Anyviofaeiano;'Sec[icn=03;.56�
.-,.<.,�,..�-��.Pr.... y
� - .. . ��l �"4���� Dafe Received � ar:y eAH%ir;�n:fo;�F,€�rmii su�lects%he anP?i4,9n'`O a eivif
A�:�'C�421s � Y�S A70 O�A''1PPOYlDC --.__..�' _ �__'_� . ^�_ �8/!2?If Oi f10;iYf6IE;F;B:]fllC�%JiOlBFi UDiI3lS;�J�QGJ.J.
�____________ __ - ❑ l,asovtn�rof;;iepioPerty,ormyenploYeeswi±h
VraeerCar±ifica.Ye---- --� ` . ' - __.�---�_.._-- _-._ .._,._._�_.w.._,_.._ ��nagesseth23rsnlecompensa4!on;wiildcYhewark,and
1 the�!ru�fu�e is ro2 inten��ed orvffer�=d`:ors2le(Sac.?04A;
` -���____�..._ _ �.--.-- ,-- 6us;ness�7d P:�ia�sions Code:.T,he Cr.nt,acfo;'s i.icer,se
tiy2iqh Depa.r[rseni � r.ar s�a&3 not app;y.c an a��ner of,u,oper:y w;ho buil7s
F:,e Deparfiner;t � .�. � -_ _.__.�..��...._.�.. _----�,� ._. . .�;irriprnv�o therao^,and nhc���5 Fuch+an.=k.himse;{o>
___,�____J �fhro��gh ris avrn cmplcyaes,utnsida�Phs?such !m-
! � /s�o��e,r,anP� 3rs rof !nPen�ed*�r ofie:sd !ur�^�le. /t,
Gr��;r9^.__��_� � � .hovr�ver:t!,?�c�;rdir:y sr�mprovamsrTis:su?N.�r,•ithinone
� yas.of curn;aJe?ien,:i!e o;d.ner-bui!der�r,�!;��&:�c the burder
jGeclogiaal . . ---- ' --..-._.__.� -_ oipror,•.agpha?hgdidnofbuildcrim;ar�;ve'artheDur,ocse
P� sd=sfriar;P.e:ecfion I ."'-`"'--'�"�-""'."�_-"-""�� ------ of saie;. � .-
�(FencE)(CanoPY` � � ' - ' ❑' �,�S ONliOf r?th9 pTCnB;sY,&ff?e;!CIu3i�,g;y C3i'.-
� _ . .�.._____.___.-.._-----��_�, _._.._. 8rae:l�g wi:i I';csnsed�ontra,^,i�rs!n cens4r::c.?fia Pra-
r..�___._-__�_._.__. . 'ec:!5ar,.7�44)3usin�s.s e.r,d Protesslonu e�L�E:'hE COP-
�5 PCin_I inSrEGSior, i osap,.iptc SROkYhE'CQF�/G-
� F/u3onr lr4�e�tEiltC� ^.---- __ ...._�........�...,..._�e.�.T_�-.__.__.�.. 118CPGi�S:.,'CC€Ti£2L7.iY�C9S.'
(Cor.c.)(.; Y)l S; � � . . per!;r whc b:�il�s e,::n.pmves Phereon,;ntl o-ahc oor,tran?s
. ._.-`� - !o>such pro/ea°s wr;h a conirac,+�a/s)?ie.sr.aea,^u,suan'
lo[YrairuflE ._...�....,. . ..._._......�..,..,.r..._....�..._. . "_'_"' t0 ChE CO�C°�CPOf'S i.]CE:fSF."LBWf.
Parkinu -_R.._....�._.__ __....�.A.._.__ .�._.__ ❑ 4 am sxsmp:;:nd¢r s6.^>._._�8.&.?.C.Sc[°�5is
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Y .����-nsa;s^— GaEe fnsAee9or's 5lgnature ""'.'-."""_......-_� _.___� .. .. . _.._ _.�,.._,-.� . _ _ _
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S�SP�EC'i.'1,Sf'S?�EOTES� �
Locafior- --_ _..._�____.�___,.._�...__�...� _� ._..._._....__._...,_�.___'..___.r.,.�,,._.,..
,._.<..s...............�..,.�.._,....
(SetGack 3 Yards; ��_^_ �� �
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Energy Insu�atlon �
i LatF.lG.ry.aail- _ __- � �--_'-_.__._..._.._ �. �.�.. .,. . . '. ._.__ .__._..._. . _ , '
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