HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (48) �,�A.. ._�_. �r,._ ._ .... __.._ - -- . - - ------- - - - - -- -- _. . ---- . - ----
�WORKERS'COMPENSAiION DECLARATION � `
� hereby affirm that I have a certificpfe of mnsent fo self APPLICATION FOR �I�ILDING PERIIAIT
��-f'p insure,or a certifimte of Workers'Compensation Insurance,
or a�ertified copy rhereof(Se�.3800,Lab.C.) COUNTY OF LOS ANGELES SUIIDING AND SAFETY
PolicyNo.� � � Company ' "� '
� Cerrified<opy is hereby fumrshed. FOR APPLICANT TO FILL W Bu���wG " j , �_
ACDRE55
� Cerfified copy is filed with the munty building inspeo- gUILDiNG .- -
tion depariment. ADDRESS
Date ' � Applkam �� � � - -� aiY�� ZiP � ���
LOCALITY
CERTIFlCA7E OF EXEMPTION FROM WORKERS' � NO.OF B�DGS. NEAREST
COMPENSATION WSURANCE SIZE OF LOT NOW ON LOi CR0.5S ST.
(This secfion need not be completed if the permii is for one ASSESSOR
_ hundred dollars($100)or less.) TRACT BLOCK LOT NO. Mp,P gpOK PAGE PARCEL a
7EL. '� '� .... USE ZONE �P
I certify that in the performance of the work for which this OWNER�� ` � ' �- � � NO.' N� 1: - U
permit is issued,I sholl not employ any person in any manner "� . - ' - SPECIAL W
so as ro become subjec�fo the Workers'Compensation Lqws. ADDRE55 ' ' CONDITIONS �
CITY �.,. .., .. ZIP '�' ' LL
Date Applicant ARCHITECT QR, , ' TEL ', nP �
NOTICE TO APPLICANT: If, afier moking this Certifimfe af ENGWEER '- ' - ' " �� � '' NO.% 'f,�% ' ' DISTRICT GROUP 7YPE FIRE PROCESSEo BY Q
Exemption, you should bemme subject to the Workers' CONST. ZONE �
Compensation provisions of ihe Labor Code,you must forth- qDDRE55 - ` �� " � !J � ' � ' - �
with compiy with sucn provisions or this permii sho!I be TEL.' �� . STATIS7ICAL CLASSIFICATION APT. CO�00. a
deemed revoked. CONiRACTOR � ' � ��' / ' �- NO.=' ' y�j
LICENSE�CONTRAQORS DECLARATION ���. CIASS NO. �� DWELL.UNITS �"'
. I hereby offirm thpi I am licensed under provisions of Chapter 9 ADDRE55 - " � NO. '� f` "' �
(commen<ing with Section 7000�of Division 3 of the Business and uC. SEWER MAP
Professions Code,and my license is in full force and effed. CiTY/�'''� % -�'': CLASS' �y'� BK � VALIDATION
5�.FT. NO.OF NO.OF CHECK
License Number � Lic.Class �' � � SIZE STORIES FAMIUES ONE
l ALUATION
'�: .'.= , . . �ESCRIPTIONOFWORK NEW ❑ S ,_ ' "t ,, "'
Contractor ' " �'Date ❑ . �
ADD
�I pm exempt under Sec ' ' � � � ' ' a , �' ..,
ALTER
B.&P.C.for this reason - � ` � -� 'r' � S � ''�•'
REPAiR ,� ..-..�
Dafe: USE OF , DEMOL
EXIS7ING BLDG. � ' ' ' �
Signafure APPLICANT .i.:' , � ..� TEL. . F1NAL , ' ,�''
OWNER-BUILDERDECLARATION � (PRiNT� - -"� NO.` pqTE ���
I hereby affirm ihot I am exempt from the Conirocror's License , i , . , , �,,�;"
Law for the followinq reason (Section�031.5, Business and ADDRE55 - ' FlNAL
Professions Code): PRESEN7 8Y
aBUILDING
I, os owner of fhe properfy, or my employees with ADDRE55
wages as their sole compensotion,will do�he work and , '
ihe siructure is not intended or offered for sale(Section ��E'��TY
7044,Business and Professions Code). MOVING 7EL.
� I,as owner of the property,am exclusively contracfing CONTRACTOR NO. ,. � �,+�
with licensed contractors to wnstruct the project(Sec- qDDRE55 �
tion 7044,Business and Professions Code). ; d Q'y z a +.
REOUIRED iOTAI SETBACK M T. � '�� ��'
CONSTRUC7ION LENDING AGENCV SE7 BACK Y/aRD HWY pROP.LINE WIDTH
I hereby affirm that there is a construction lending agenry 4or FRONT � � ^,s.� .��.�:��,
the performance of the work for which this permit is issued P.L � �
(Sec.3097,Civ.C.). SIDE !.n,t��.t'...°,,,,;�:�.
.. . . . . P.L . .
Lender's Name ' � , ioMA Ref.# �":�'S.`��;���
- Lender's Address P.C.Fee 5 Permir Fee � '
I certlfy fhot I hove read this applimiion and sfate that the Issuance Fee � L�MA P/C�.
obove information is correct.I ogree to comply with all County Invesiigo��on Fee "�
ordinances and State laws re�a�ing fo building<onsfruciion, Total Fee � �� L�MA Perm.#
ond here6y authorize represenfatives of this Coumy to enter
upon ihe above-mentioned properry for inspection purposes. � �
�-- � + � SEE REVERSE FOR E%PLANA70RY IANGUAGE
l5ignot�re of Applicanr or Agent Dare , C-