HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (47) WORKERS'COMPENSATION DECLARATION � �
- I hereby af4irm that I nave a certifimte of mnsent to self � ��
insure,oraceriificateofWorkers'Compensafion��s��a��e, APPLICATION FOR� �UILDING PERMIT
or a ce�ri?:ed copy'hereof($ec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY --
Policy�Nc. Company '� \,�
Cerii*ied co s hereb furnished. BUILDING `
❑ pY' Y FOR APPLICANT TO FILL IN ADDRESS +' A~9` �;
� Certified copy is filed with the county building inspec- BUILDING � - ^-"' � ' ' "
tion department. ADDRE55 � � - LOCALI7Y ;.
NEAREST '�� ^�
Date Applicane - CITY ZiP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF Bl�GS. ASSESSOR �
SIZE OF LOi NOW ON LOT MAP BOOK PAGE PARCEL '�^
COMPENSATION INSURANCE �
(This secfion need not be completed if ihe permit is for one 7RACT BLOCK LOT NO. USE ZONE NOAP �
hundred dollors($100)or less.) �
TEL. SPECIAL �
I ceriity that in the performance of ihe work for whicn this OWNER NO. CONDITIONS �
permif is iss�ed,I shall nat employ ony person in any manner DISTRICT .GROUP 7VPE FIRE PROCESSED BY �
so as to become subject to rhe Workers'Compensation Laws. A�DRE55 CONST�,r,.-� z^^O�IE �
�afe_i'i". .- ..�,E' `+ .'.'-"�..;�%�>= /� ,,';4 CITY ZIP . ' .� �..�. '.,� .t.:�.-,,,,.. (�( . �,:''..1 '`,; - �
Applican! ' � � � ' qRCHi7ECTOR 7EL SiA715TICALCLASSIFICATION � APT. CONDO. �
NOTICF TO APPLiCANT: If, afler makj7ig fhis Cenificqte'Of�+ ENGINEER NO. CLASSNO. DWELL.UNITS �
Exemption, you shauld become subject to the Workers'
Compensalion provisions of the Labor Code,yo�m�st forth- qpoRE55 SEWER MAP d'
with <omply wi!h such provisions or this permit shall be �
deemed revoked. TEL... .
CONTRACTOR;',' Np,""' BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARA710N ��� �IC.
!hereby effirm thet I am licensed under provisions of Chapter 9 AD�RESS ' � �'.:!i.`,�.,�".: NO.=;�=' r yq�UATION
(commencing wiih Sec�ion 7000)of Division 3 of the Business and � � � . � LIC. �� ,�
Professions Code,and my license is in full force ond effect. CiTY t� •;;'�� /'',*.�:,,.;. CLASS r "t"� S ,
SQ.FT. NO.OF NO.OF CHECK
License Number �� Lic.Class - - SIZE STORIES FAMILIES ONE
NEW � g
r,%:,:`� _ �� DESCRIPTION OF WORK �
Contractor�:� ,..-- "= - '-'Dote - ADD �
❑I am exempt under Sec. n�ieR ❑ FINAL � �
B.BP.C.for this reoson � DATE "'` `"�"`�
REPAIR
Date: EXIST�ING BLDG. �EMOL � FINAL ;:.°.�W�.g .. .
B w ..
$ignafure_ APPllCANT TEL.;•.�� Y , s �'�.�,.;,,A.;. i.�
� OWNER-6UILDER DECCARATION (PRINT��. _ NO.�,- �,' , .
I hereby affirm fhat I am exempt from the Contractor's License ' ;+;s..b;� :�!.�����,
Low for ihe tollowing reason (Seciion 7031.5, Business ond ADDRE55 � :_'i „ �
Professiors Code): PRE T �;�,(:.C."":•���
. ❑ BUILOING � ,. � �, �
I, ❑s owrer of the properry, or my employees with ADDRE55 `*�'�;;��
wages as their sole compensaYion,will do ihe work and '
9he strucfure is not intended or offered for sale(Section �OCALITY ', � a,�;���.�
7044,8osiness and Professions Code). MOVING TEL. �� � + � �
� � I,as owner of ihe o ert am exclusivel contractin CONTRACTOR NO. i,� .�;�`s
P� p Y, Y 9' .�e;;,,�.,�
with licensed cor.iracrors to construct the proiect(Sec- qDDRESS
tion 7044,Business pnd Professions Code. ' ' '��� �� � d
) m N.a,:e;-','+.( ;
RE4UIRED TOTAL SETBACK FROM EXIST " '
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH
I hereb affirm ih t there is a construction lendin o enc for 1.u��:.`"�
Y 9 9 Y FRONT ,"�j;:';.
ihe performenc�f the work for which ihis permit is issued. p.i. ,
� (Sec.3097,Civ.?C.). - SIDE
- P.L.
Lender's Name
� P.C.Fee S Perm�r Fee
- Lender's Address
1 certify that I have read ihis applimtion and state that ihe Issuance Fee
i abave informotion is correct.I agree to comply with ail County' In�es+�gorion Fee
'3 ordinances and State lows relating to building consiruction, imal Fee
and hereby authorize representatives of this County�o enter
Rupon the above-meniioned properiy for inspection purposes.
o • ';"-� SEE REYERSE FOR EXPLANATORY LANGUAGE
• . ;%`
�Signafure of Appli�canf or.4gent�� f Dafe
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