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HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (50) WORKER5 COMPENSATION DECLARATION I hereby affrm that I hove a cer�ficote ot consent io self APPLICATION �F�OR�-�UILDI-N�G� PERMIT � insure,or a certif mte of Workers'Compensot on Insuronce, � 7� or a certified copy thereof(Sec. 3800,Lab.C.) ' r r�� �g� �- COUNTY OF LOS ANGELES BUILDING AND SAFETY •'; Policy hfo.rr �iW.,., 'eCompany ..��; ��. , .''d r ,. . . . - ,. . BUILDING�,, ��_ ❑ Cernfied copy is hereby furnished FOR APPLICANT TO FILL IN ADDRE55; , �!'./',�ix! � - Q. Certified copy is filed with the county building insper BUiLDiNG .t, ;i��� ; �� � , ' tion departmen}. ADDRESS : _ ry 1.,),'�j ' :' .':'., ;�:. 6`":fi; �. .... CITY _..r _,ZIP LOCALITY ' ��-' „ c: '"�t..r:,.�\.i. ; <�',%`'-". Date" Applicpnt �- �-� - � f CERTIFICATE�6F EXEMPTION PROM WORKERS' � NO.OF BIDGs. NEARESi . . �� COMPENSATION INSURANCE � SiZE OF tOi Now oN�Ot cR055 5?. �� F":�^`��t�' �'���'"� This seciion need not be com leted if the mit is for one TRACT BLOCK LOT NO. /SSESSOR ( p per MqP BOOK PAGE PARCEI hundred dollars($i00)or less.) ,_.-f � TEL. � OWNER � �� �! NO. USE ZONE �P , <.- - .. I certify that in the performance of ihe work for which this � r..� NO. SPECIAL permit is issued,I shall not employ pny person in any manner A�DRE55 - � CONDITIONS d so as to bemme subject to the Workers'Compensation Laws. � ary z�a V Dafe AppliCont ARCHITER OR TEL. OISTRICi GROUP TYPE FIRE PROCESSED BY � NOTICE TO APPLICANi: If, oker making this Certificate of ENGiNEEk NC. CONST. ZONE � Exemption, you should become subjed to fhe Workers' ,j , r,,r, Compensation provisions of ihe Labor Code,yau musf forih- AD�RE55 � � � � wiih comply iih s�ch provisions or }his permii shall be �, �, _ �TEL. STATISTICAL CLASSIFICAiION..' APT. NDO. Q deemed revoked'. CONTRAC70R �•_ ' "-NO. � � LICENSED CONTRACTORS DECLARATION . uC.,-;,,,, CLA55 NO. " � oWELL UNiTS � I hereby affirm that I am licensed under provisions of Chapter 9 AODRE55 � � NO.�" (commencing with Section 7000)of Division 3 of ihe Business �, � � r. uC. SEWER nMP W �.r"i-�..;r.,:<.�. qnd Professions Code,and my license is in full forCe and effect. CITY ; ?-J-t;i�'.� �-" C�� '�"� gK � VALIDATION r . �� SQ.FL t j p-- NO.OF NO.OF CHECK Li[ense Number � � : - Lic Closs SIZE ; � STORIES FAMILIES ONE - � � . � VALUATION j��-�4"` �ESCRIPTION OF WORK � NEW %�}. f, � , Contractor-�� �, ' '� - Date �" � $ ��' � . �I pm exempt�nder Sec.� '�� �� ` A�R � , r,r. „•, 7�^�. B.&P.C.for thls reason �'��"''��f � � '�� �� �� REPAiR❑ $ ' � ' ': '�e:a:m s C.:..: � D te: USE OF � EX�STING BLDG DEMOL❑ G f Signature .. • .':'�..' . ��;'':--r''"...� APPIICANT :TEL , FINAL .1 ! ��. ,.-`"`\ OWNER BUILDER DECLARATION (PRINT) , :_+'�^:�` ���ti 'v NO - - . I hereby affirm that I am exempt from the Contracror's License . �-.. :;� � .... �� f Y DATE , � ,,,,�,,,, , �.......� , ama ; �j'^•�� ,�. � :.'�a..,r_. ,� : Low for the followin reason Section 7031.5, Business pnd ADDRE55 + " FINAL '� 9 t �!.��.d.�'�"'�C�,. �. Professions Code): PRESEN7 By ❑ I, as owner of ihe ro ert, or m em lo ees with BUILDING P P Y Y P Y ADDRE55 wages os their sole wmpensation,w.il I do the work ond �pCALITY , the structure is not intended or offered for sale(Section 7044,Business and Professions Code.) MOVING 7E1. ❑ I,os owner of ihe property,om exclusively mNrading CONTRACTOR NO. with licensed mniradors to consfrucf ihe praject(Sec- qDDRE55 , :.€r r�y., tion 7044,Business and Professions Code.) - � -� '` � '-�'��� -��'" REQUIRED TOTAL SETBACK FROM EXIST. ' CONSTRUCTION LENDING AGENCY Seran ,e ��+RD hiwV pgoa.uNe wi�TH ��°�°��°�`.,3; I hereby affirm thpf ihere is o consiruction lending agency for FRONT . .. . the performance of the work for wMich this permif is issued P��� t1'��a.!:�6`=f�'` (Sec.3097,Civ.C.). SIOE , ,..H P.L. r s�a�;��:G�.! �'�'r Lender's Name t"l��� - LDMA Ref.N !. F:c'`�,:"� :4�_, � � P.C.Fee$ !�`�� Permit Fee - " , ���� Lender's Address , I ertify thot I hove read ihis applimtion and state fhat the Issua�ce Fee - 5"� L�MA PiC H - above information is correct.I agree to comply with all County �nvesrigotion Fee ��' ep� ordinances and State lows relating to building construdion, Totai Fee ' L�MA Pe�m.H and hereby auihorize representatives of thls County to enter upon,ihe above-mentioned property for inspecfion purposes. , - °'%�'� ' � SEE REVERSE FOR EXPLANATORY LANGUAGE � �Signet�re of Appliwn�or Agenr pote � - . 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