HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (7) ---�-- ------- —�.._._ _ _____ �.--
�.y� jay {
P"` "'"� WORKERS'COMPENSATION DECIARATION ' �' � �� `
i hereEr;:aifirm rha�I have a certificote af�a�=e�,�o self A P P L I CAT I O N F�O R B U I L D I N G �P E RIVI��
�insure,or o cerfificofe of Workeri Compensalion Insuronce, ,
or o certified mpy thereaf(Sec 3800,Lob.C.)
COUNTY Of LOS ANGELES BUILDING AND SAPETY
Policy No. Compony BUIIDIN.G
� Cer�ified copy is he�eby to�nished. fOR APPLICANT TO FILL fN ADDRE55 �/�.s �. �-�+�-�-+•-� �
� Certified copy is filed with the county 6oilding inspeo- guaolNG 3
tion deporiment. aDDRE55 f fjr �
Dafe Applitont CITY � � ZIP � a LOCAUTY
CERTIFICATE OF EXEMPTION FROM WORKER$' NO.OF BtDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CRCLS$ST.
(This section need no�be mmpleled if the permiT is for one ASSE'SOR
hundred dollors($100)o�Iess.� TRACT BLOCX LOT NO. µqP BOOK PAGE PARCEL
OWNER s>c � NO.OK�'r(`%� USE ZONE N�4P ///� �_/
I certify thof in�he performonce of the work for which�his In• SPEpAL `V d
permit is issued,I shall not employ any person in ony monner qDDRE55 �+�� COMDITIONS �
So os to become subject to the Workers'Compensotian Lows.
u
CITY Z�P K
Date Applicont ARCHITECT OR TEL. � O
NOTICE TO APPLICANT: If, oher moking this Certificate of ENGWEER NO. O157RICT GROUP tYFE FIRE PROCESSEO Bv �
Exemption, you should become subjact to the Wo+keri !� �y OONSi. ZONE W
Compenwtion provisions of fhe Lobor Code,you musf forlh- qDDRE55 •"�y d
with comply with such provisions or this permit shail be
deemed revoked. TE�� S7A71571G4L CtAS$IFICATION APr. CONDO. Z
CONTRACTOR NO.
UCENSED CONTRACTORS�EClARA110N �iC_ CLASS NO. z DWELL.UNITS
t heieby afFirm lhq�I om licensed under pro�isions of Chopter 9 AD�RESS NO.
(commencing with Section 7000)of Div+sion 3 of the Business and ��� SEWER MAP
Professions Code,and my license is in full force and effect. CI7V C1A55 BK � VALIDA�ION
SO.Fi. / / NO.OF NO,pF CHECX
Cicense Numbar Lic.Class SIZE 1�t.J STORIES FAMIUES "�� ONE
VALUATION
-�"`C.onfractor Date DESCRIV710N OF W/ORK • AD S ��� �
�I am exempt undar Sec. �� ��C4�+ �C'� �G6L Illt' ,
ALTER
B.&P.C.for lhis reason REPAIR � s � • `�`�� `��'
DafO: E STNG BL�G. DEMOL � �; � � • •G v
$ignature APPtICAN /� 7E1.
PRINT � �47 NO.� - C' 4`. FNNAL � « s�J.C G
OWNER-BUILOER DECIARATION �AtE
1 hereby affirm ihat I am exempt irom ihe Contractoi s Liceose m�- f x .- - .-`
Law for�he io��owing reasan(Section 7031.5, Business and A�DRE55 I�F N. " L��' FI pL � °c J�,i;!:
Prafessions Code): a.. 8
� euuoiN � �3-l7b h �r-� i i.1 �—8 c
I, os owner of fhe property, or my employees with ADDRE55
wages os�heir sole wmpensation,will do the work and �A TY �j� -(��J� �o�iQ� �, S�T�'(�(�,J 9p., elD7' ��
�he str�cture is not intended or offered for sale(Section �
704d,Business and Professions Cade). MOVING TE�. S�OW(n5� ,L���,�ea ����V��
I,as owner of the property,om exdusively mniracting ��TRACTOR NO. 11 p
� with litensed contractors to consfruc�fhe project(Sec- qpDRE55 ��� A�"� T�1��� �u "�� o�y"� [�. ��(C
�ion 704a,B�siness and Professions Code). je'�
CONSTRUCTION LENDING AGENCY �7�gq[� YARD HWY T�TAp OPe LME WIDTH J��� � T�� �dLL ��� ��� �6�
I hereby affirm ihoi ihere is a mnslruciion lending ogency for FROM �� � �Ot(o�{. �iC.�}E $fljZS 3l)
ihe performonce of the work for which fhis permit is issued P.L. �� ��
(Sec.3097.Civ.C.). SiDE ��tN�� 5(�-tr �c
n P.t.
� Lender'sNome �C�O�,
� LDMA Ref.A
P.C.Fee$ �'r Perm��fea ,
- tender's Address
I certify that i have reod Yhis ppplicotion ond slafe thai fhe laauonce Pee LDMA P/C M
abo�e in4wmotion is correcr.I ogree to comply with oll County m�es��gm�o�Fee
; wdirwnces ond State laws relating to building consir�tfion, ioral fee LD:.AA Perm.JI
and hereby outhoriza reprasentatives of}his County fo enter
; upon the abov-mentioned ro gty for inspection purposes.
GJ /` F � ��•-1 7,'�i SEE REVERSE FOR E%PLANATORV iANGUAGE
��
Signoture of Appliconf or Age Date ��
�