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Home My WebLink About1155 SOUTH DIAMOND BAR BLVD (28) __ _. _ _.,., . .. ,.._ ._ . _... . .. . ... . ... WORKERS'COMPENSATION DECIARATION � ' � ' � .. " . .. .. . .. . _ _ . . , . _ . I hereby affirm ihat I have a certificate,of cons.ent to 5e�f � ,� APPLICATrO�V ��QR B[11LDING -PEI�MIT- - � insure,or a certifica�e of Workers'Compensation�insurance, or a cerrified copy thereof(Sea 3800,-Cab.C.) � � � - � � COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company . .. ....' ..' �-.�.._'... . .. �7 � . � Certified copy is hereby turnished. FOR APPLICANT TO FILL IN nooaEss �/��.r - �, / � Certified copy is filed with rhe munry building insper - BUILDING [!, � � ,�� (� L� /1 tion department. ADDRE55 �„j 4,9 �-� Da�e Applitdnt CITY'L,J� ZIP IOCALITY . .. . . . . - CERTIFICATE OF EXEMPTION FROM WbRKER5' NO.OF BtDGS. NEAREST COMPENSAiION INSURANCE SIZE OF LOT NOW ON LO7 CRO55 ST. (This section need not be completed if the permit is for one ASSESSOR ' bundred dollar5($100)or less.) TRACT BLOCK LOT ND. /y�,qp gpOK PAGE PAR�L ' �f N��'f�" USE ZONE �P f�� OWNER f i certify�ihat in ihe performance of the.�work for which this ^+�� /� � �.-� SPECIAL Z � G�. permif is issued,I shall noi employ any person in any manner qpDRE55 i d �kkJ so as to hecome su6ject to ihe Workers'Comp�nsation�ows. � (�� CONDITIONS � � � . . . �. . � CIN ��J � �y ZIP �f+K(7� p� Date Applicant qRCHITEC7 OR TE��7� DIS7RIC7 GROUP TVPE FIRE PROCESSED BY � NOTICE TO APPLICANT: If, after making this Certificare of ENGINEER G' rv0. '- /� CONST. ZONE W Exemption, yo� should become subjec� to the Workers' y�, ��^��.,�- Compensafion provisions ot the Labor Code,you must forth- pD�RE55 . f+'J,�.,. .. J G- with comply with such provisions or ihis permif sholl be � " """TEL:")�2� ,.p STATISTICAL CLASSIFICATION APT. CONDO. � deemed revaked. CONTRACTOR O. ! LICENSED CONTRACTORS DECLAR.4TION ,p �,p -� � -LiC. � � CLA55 NQ �"� DWELL UNIiS I hereby affirm fhaf I am licensed under provisions of Chapter 9 AD�RESS t}� 7=71� NO. (mmmencing with Section 7000)of Division 3 of the Business and �� SEwE&Mav Protessions Code,and my license is in fulf force and effect. CITY o � CLASS ' BK � . VALIDATION � � SQ.FT. ,�NO.OF NO.OF CHECK Litense Number Lic.Closs � - SIZE a.,(.�� STORIES FAMIUES ONE - p� VALUATIOM DESCRIPTION OF WORK NEW 1:Y �7 7�j,� A CoNractor pofe � App � $ �I am exempt under Sec. � �"� L, A�iER � ' �• • � �G`� B.&P.C.for�his reason .. �I.��^ �� REPAIR ❑ a � • e G 5.�� USE OF Dafe: EXISTING BLDG. �FMOI ❑ s ` r Signafure ... APPIICAM,�a � �p TEL 1 �px.a FINAL �l 5.�U J OWNER-BUIL�ER DECLARATION PRINT c�'� '�f NO. DATE . �O 5,2� -H 6 1 hereby affirm thot I am exempt from ihe Caniractor's License �'� � �GwC ,J (��' FINAL Law for the following reason(Section 7031.5, Business and ADDRES Professions Code): �� PRESENT - BY QBUILDING .... . ..._ ._ i, as owner of 1he properly, or my employees wiih ADDRESS wages as their sole compensafion,will do the work and � the strudure is no�intended or offered for sale(Sec�ion ��f`��tY p G � 7044,Business ond Professians Code). nnOviNG TE�. ' �:-i"!R��'�� -�l'7,�• r��,�A � I,os owner of the property,am exdusively mntracting CONTRACTOR NO. �. with licensed mntrodars to construct ihe project(Seo qDDRESS Y,`r� e es t G,j iion 7044,Business and Professions Code). REQUIRED _, TOTAL SETBACK FROM XI T. CONSTRUCTION LENDING AGENCY� � - SET BACK YARD HWY pRpp,�INE WIDTH �, { � I G � I,"i�G O I hereby affirm that there is a construction lending agency 4or FRON7 J p''' the perfo�mance of the work for which Ihis permit is issued P.i. j',l.L��y-� r�,.�""" � :: � �ra C G,,,x (Sec 3097,Civ.C.). SIDE �'� P.L. Lender's Name U Q I �"�R O - .«7 n LDMA Ref.N - Lender's Address P.C.Fee$ �GS� ---- Permlt Fee ' ' I certify}hat I have read this appiication and state that the Issoance Fee LDMA PiC# ¢ o6ove information is correcf.I agree to comply with all Counry investigation Pee _ _ � ordinance,s and State laws relating to building construction, Twol Fee LDMA Perm.# � i, d hP eby `horize representatives of ihis County io enter x u n 1 ab EnN ed property for inspection p poses. ' � ^ ' � ( �r�� t,/ SEE REVERSE FOR EXPLANATORV LANGUAGE � a � '� Signoture of Appl�mnf� Agem Dote ' " ' " ' � ' �� .�.. �.��.,a.�m...n.....,vur.v�-ar._m,r..c.vc. �.�...��..m.�e,..-..�.=r.,�.._' ....�.....�.�,.�.�.._.__.m...__......+r:,.er�.�..c+,.{�.n-a+.m�.-.�.�.—�—�.�....,�-vc..w.T.�-+m...�r+c.� 1�'r� . � . PLANS TO APPLICANT INSVECTOR'S NOTES OW\ER-BUII.DER DECLARATION . . I he.eby affirm that I am ezempt from 9he�Cantractor's To: � Returned License -Caw for'ihe following reason. ($ec. 7D31.51 � Approved BUi4HCF54AlI PY!)fessioxs Code:Any tity or roanty whicb No. DaTe No. Date requires u J�ermr[to ca ctruct,r�lter,imprae�e,dernnlisb, or repuir an y sEructure,prior tn rts issuance,akn regudres the applicarzt for ruch permia to,jile a siqned stutement rbar h�,is I:.:�xseJpursvane eo th�pro„is:o�s of ehe Con- tracior's Lirnresv Law/Cbapter 9)/commencing witfi Ser [ion 7000J J Dinisian 3 of lhe Buaines.e and Proje.rsinns Cnde/or tbut he i.v exempt tberefrom und ihe bru�is jor tbe a[le,Qed c.uemplinn.Any x�iolation of Sectinn 7031.5 by Required Dafe Reteived uxv applicant�or a permit subjecte�the aJ�plicant tn a cix�il Approrals or Approved penalty of no�more tfiun Jrne hundred do(Jurs($500/./: Yes No - 'l I,as owne�of ihe property,or my employees with Woter Certificate . . wages as iheir sole compensation,will do the work,ond the siru<ture is nol intended or offered for sale(Sec.7044) Healfh Department - . IIusfness�axd Prnfes.��ons Code:Tb�Contructor's I icensv Law dnes noi apply[o nn o�uner of properly u'bo builds Fire Depariment _ nr imprnves thereon,und whn does such work hirruel(or . . tirough his ow�n empl�iyees, proa�iJed lhut xuch im- 6rading - prouements are �e,nt intendad or offered Jor sale. If. � � � hower�er,the buildeng or impmnement i.��sold uvthin one Geological � yeur n/��nmple[ion, tbe ow^ner-buifder u�i7l have tbe . hurden nf prr a�in,�that fie d"ul not 8uild or impmx�e f�r . . t5r p:,rpnse qf.cule). Pedestripn Protecrion - (Fence)(Canopy) [''�� I,os owner of ihe property,om ezdusivelyconiroc ting with licensed controctors ro constr�ct the project(Sec. Special Inspection 7044)Busiaz�s nnd Pr fessinnx Code: �Tbe Contruetnr:c (Conc.)(Masonry)(Welding) . � Limnse l.aw does nnt a(ifrly in¢n oumer ofprupert.y u�bn builds or im.proves thereon,und:rhn cnretracls for sucl Lo�Droinoge projects u�i!! u rnntractnr(sJ Tirensed pursuaxl tr the Camtru�tor's Lirer�se l.uwJ. Parking [ I am exempt�nder Sec. ,B.BP.C.for rhis reason __.._..._.__ '_ .' Dote Owner Approvals Dn1e Inspecfor's Signature - � INSPECTOR'S NOTES Location— (Serback&Yords) Foundations Slab Frame Energy Insulation � Lath/Drywoll �� Inierior Loth-Exterior House Number Correct&Posted Pinal-- Enier on Fronf