HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (24) ��' .. WORKERS'COMPCVSATION DECLARATION " . �
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insuretoraofcertifca'te of WorkersrrCompensa�ion Insuran elf APPLICATION FOti BtJI-L.. I�, �� G PERMIT
or a certified copy thereof(Sec.3600,Lab.C.) COUNTY OF LOS ANGELES , BUILDING AND SAFETY S��
PQolicyNo. Company . .. BUILDING C� � � ��,�
Certified copy is hereby furnished. FOR APPL�CANT TO F�LL�IN nDDRE55 1
� Certified copy is filed with fhe county building inspec- BUILDING ] p� ,
tion dBpaf}menf. A�DRESS p .,j s � ,� ��'v/ ' ,~ ^�nR CALITY
� NEAREST
Dale Applicant CITV .����� IP CROSS 5T. �
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSE550R
COMPENSATION INSURANCE SIZE OF lOT NOW ON LOT N.°.P BOOK PAGE PARCEL
(This section need not be completed if ihe permii is for one USE ZONE �nAP
hundred dollars $lOD or less. TRACT BLOCK LOT NO. NO.
( J � ;EL. . / SPECIAL 9�
I certif that in ihe erformance e work tor which ihis OWNER c•G�- � ��//�- O. CON�ITIONS �-
Y P pISTRICT GROUP TYPE FIRE PROCESSED BY �
ermit is issued,I shall not em la a ers in an ma er �-'� r,�7�,�� Ci
so ns ta become subjecl fo 1he ,rl � npensa� s. ADDRE55 ..5 , 7� ��� ,� CO {__'L` i;ONE �n� �
J— CIN !"l��v� .L3��P V sv ,�•�r.o� �
Date Applican � �� SiaTIS71CALCLA551FICATiON APT. CONDO. �
NOTICE TO APPLICANT: If, after making ihis Certificate of ARCHITECi OR .TEL.y
Exemption, you should become subject fo ihE Workers' ENGINEER /H C. ��/ ' ClASS NO. DWELL.UNITS �
Compensation provisions of ihe La6or Code,you must forih- qDDRE55 �1 41 d �'`� SEWER MAP ��
ith comply 'th such provisions or ihis permit shall be • TE� �
deemed revoked. CONTRACiDR NO. BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LiG .
I hereby affirm ihat I am licensed under provisions of Chopter 9 ADDRE55 NO. VALUATION
(commencing with Section 7000J of Division 3 of ihe Business and �iC. �
Pro4essions Code,and my license is in full force ond effect. CITY CtA55 $ ,
Sa.FT. NO.OF NO.OF CHECK
Litense Num6er Lic.CIa55 SIZE STORIES FAMILIES ONE
DESCRIPiION OF WORK
NEW � 5
Contracfor Dafe ADD � ���.�.E,(`j rj
�I om ezempt�nder Sec. ���'�� S�� AL7ER � FANA� �� t e � g
❑ DATE °Z i
8.8P.C.for ihis reason REPAIR
Date: USE OF DEMOL ❑ F1NAL 1 q 6 i j,(1(�
��� EXISTING BLDG. BY
Signafure APPLICANT • � � TEL _�r - '� �, i ��,�;.�;J�
� OWNER-BUIIDER DECLARATION PRINT , f �c-*s�NO.S ts
I hereby affirm that I am exempt from ihe Contractor's License qpDRE55 ;,l ��� �L"' ��/�c n'�� , f j•G ���b
Law for the following reason(Se<tion 7031.5, Business and
Professions Code): PR NT K,�U-�� �{'
� �UILDMG rs e
` I, as owner of ihe property, or my employees wifh AD�RE55
woges as their sole compensation,will do the work and i% � 'i° �
ihe siructure is not intended ar offered far sole(Section tOCALiTY
7044,Business ond Professions Code). MOVING TE�� � ° E J Q 5 C'
� NTRACTOR NO.
4 I,as owner of fhe property,pm ex[lusively confracting --
1 with licensed contrattors to consKuct the projecl(Sec- qDDRE55 � � c�G•v�L
�� tion 7044,Business and Professions Code).
� REQUIRED YARD HWY TDTAL SETBAIX FROM EXIST. j ���;`(+�R(]
CONSTRUC710N LENDING AGENCY SET 6ACK PROP.LWE wiDiH �
I he�eby affirm that ihere is o construction lending agency far fRONT
ihe performance of the work for which this permit is issued P.L.
(Sec.3097,Civ.C.). SiDE
P.L.
Lender's Name (�(� (�
� P.G Fee 3 `;`1 Pe�mit Fee �JQ
Lender's Address (�
� I certify that I have read this application and state ihat the issu ce Fee V•
¢ above information is wrrect.I agree to comply with all County investigation Fee on
� ord' ces and S�ate laws relating ro building consiroction, Totol Fee
6 h �y authorize representatives of this County to enfer ,
m`� po a menti ed roperty for inspeclion purpos s - � - � -�- � �-'
" � � �,,,�L �� —"� SEEREVERSEFOR E%PLAIYATORYLANGUAGE� _ ,_ , _
� _ �s
Signature of Appl�con+or Agenl Dme
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