HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (55) WORKERS'COMPENSATION DECLARATION ' � � ��-�� . � .
I here6y affirm ihat I have a cerhficate of consenf,to self . � AP�P�.�I CAfiI O N F O R B U I L D I N G P�E RMI T� �
insure,or o certifimfe of Workers Compensqhon Insurance,
or a certified copy ihereof(Sec.3800,Lab.C.) . . .. .-.-.--..._...__�_._�._. ____.._ . .. ;....: . .... _ _
..
y---� ( COUNTY OF LOS ANGELES BUILpING AND SAFETY
Policy No�—��•'✓Qompany �h\���jCtil�. � . —..+_ _:....___'_.....__.. ._._.
� Certified�opy is hereby fur�i:hed. FOR APPLICANT 70 FILL IN � � -- Bui�oiNr' ',��.�^� 5 '�/�fj/w.,pwlJ .
A�DRE55 ��
� Certified copy is filed wi�h the munty building'nspec- gUi�DING
fion depariment. A�DRESS �:J ,1j (`,r°w/
Dare /v .'Z Applica�� aTv ,I�E�/��n�,. 3��ia iocnury ��'-t-�QN 3•��'�.
C RTIFIC TE OF EXEMPTION FROM WO KERS' NO.OF BLDGS. NEAZEST �
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CRO55 ST.
(This section need not be complefed if the permit�is for one P.SSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MqP BOOK PAGE PARCEL
iEt.
OWNER �-.. � "��at NO. USE Z1OANE �P
I certify tha�in the performance of the wark for which ihis �i —!-' SPKIAL t _ � S�� � � d.
permit is issued,I shall not employ any person in any monner qDDRESS F'S�� CONDITIONS O
so as�o become subject to Ihe Workers'�Compensation�taws. . . , . . V
Date Applican� � CiTv ZIP _ ... . p�
NOTICE�TO APPIICANT: If, afler moking this Certificate of ARCHI7EC70R ,r�„ � TE�. DISTRICT GROUP NPE FIRE PROCESSEDBY �
ENGINEER NO. � CONST. �
Exemption, yoo should�become svbjetl to the Workers' �,�,.— � . ,(�
Compensation provisions of the Lqbor Code,you must fonh- qDDRE55 (� F�C � �� W
ith compiy with such provisions or this permit shall 6e � ----� - - �-- �
Cleemed revoketl. .+' TE�� �-�y—'� SiAT15TICAL CLASSIFICATION APT. CONDO. �
CONTRACTOR� �ry L�(t � C I NO. � J'�+ewf
UCENSED CONTRACTORS DECLARATIDN �p�.c' - C�aSS NO. ��" DWELL UNiTS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE55 �,,;.,3� NO. 73� � SEVJER MAP' ' �� '
(tommencing wifh Section 7060)of Division 3 of the Business and ��� �G�i�
Professions Code,and my�icense is in full force and effect. GTY CL455 '� BK P� VALIDATION
- G� $Q.fT. � NO.OF NO.OF CHECK
License Number���'<� Lic.Class ��`� SIZE STORIES FAMIUES ONE VALUATION
. . ...... . ...... _...
CoMrac7orTl�/�'t��jf/•��'`"� vB�je�S �� �^/ DESCRIP�ION OF WORK �� L NEW y'�/� c:4"
� � Y �L.. L�� A�D S G''V , �J O�J.S A
I am ezempt under Sec.
AL1fR
B.&P.C.4or this reason L'' ��� REPAIR ❑ S �9 m E 6?J �
Date: EXISTOING BLDG. DEMOL � � ° e���C G C'
Signature APPLICANT ` ,g TEL FINAL q � / € o 0 2�,(`.C s
OWNER-BUILDER DECIARATION �tiNT) E °''R'�_ NO.����� DAT !"/� !
i hereby af{irm lhat I am exempt from the Cqntracfor's License � �'�G_�(�
Law for�he following reason (Seclion 7031.5, 8usiness and AD�aE55 � � .�� �L�'^•�- INqLr
Professions Code): E �� BY l�
� BUItoING _
I, as owner of fhe property, or my employees with ADDRESS . , ,.__,,_.,.,,
ages as fheir sole compensotion,wil I do ihe work and �OCALITv
the strucfure is not intended or offered for sale(Se��ion
7044,B�siness ond Professions Code). MOVING � TEC' "" ' e..;;O�',O A
� I,as owner of the properfy,om exdusively coniracting CONTRACTOR N�� u m
with licensed contractors ro construct the project(Seo- '� ° ° � '
tion 7044,Business and Prafessions Code). ADDRE55 c
CONSTRUCTION LENDING AGENCY ' REQUIRED yqRD HWY TOTAL SETBACK FRO %I 1 � o:;Fi 7.�
SET BACK PROP.LINE WIOTFi
I hereby affirm that ihere is a construciion lending aqency for FRONT o s
the performance of the work for which Ihis permit is issued P.L. "5','�`'
(Sec 3097,Civ.C.). SIDE � Q��,,�&�
P.L.
_ Lender's Name� . - - _- .
LDMA Ref.#
- Lender's Address ` P.C.fee$ ���� Pe.mit Fee ',�i(o�� '
I certify ihat I have read fhis applicmion and stote lhot the issoance Fee �V�y � IDMA PiC H -
p above information is correc�.I agree to mmply with cll Counry Invesrigation Fee �-
g ordi ances and State.laws relating fo building construciian, Torol Pee ,.S LDMA Perm.fi �
n '
� ond hereby authorize representatives of thpis,�Covnty to enier "
� upon � bove-mentione W�rap�ins ction purposes. .. . .•... . ,•...•_...,.�•.,"....,..�,..:..�.":�.,.:Y.:.-..>-.,".-,.� ..,,_ , . .
� �bG ... ...._,
���� � SEE REVERSE FOR EXPLANATORY IANGUAGE
^ Signofure of plicont or Agenr Date - ' ' "
1
PLANS TO APPLICANT INSPECTOR'S NOTES OWNER-BL'ILUER DECLARA'I�ION
I hereby affirm ihat I am exempt from ihe Confroctor's
To: Returned � License Law for"the following reason. (Sec 7031.5J
Approved Buslners and Professinns Code:Any city or couney whicb
re u mrt m rnnstruct,adter,im roae„demo7isb,
No. Dafe No. Date - � � - y i a per J,
. . r repav an j,stracev re,Prror to rts:ssuance,also requires
. , � t�e applicanl f r su�h permit m f'le�siQned stutement
tbai he p�lirvxsed pursuant tn the provuions nf tbe Con-
' trartor'.s License l,au�/Cbupter 9J(commerecin,g u�idh Sec-
, , _ irnrz 7000/of Uivisinn 3 of ehe liusiness unJ Protessions
_ � , Y � ' � _ � Cndel�>r tbut he is exempt iherefrnm and the ba.sis for tbe
alleged ezemption.Any niolatiott o/Section 7031.5 hy
Required Dafe Received any a¢plicantfnra permia svbjects 15e applimxt 1n a cevi!
Approvalc or Approved penu(tl'nf nnt mnre Lhan fsr�e bundred dollars($500J,�;
Yes No
._� I,as owner of ihe property,or my employees with
Wofer Cerrifimte � . .. , woges as iheir sole rompensation,will do fhe work,and
' fhe structure is not iniended or offered for sale(Sec.70441
Heahh Department �- � � � Busiieess and Professions Code:Tbe Cnntractori I.icense
l,uw does not upplv to an ouyeer o/property�u�ho burlds
Fire�epa.tment or imprones tbereom,unJ u�ho doe.v.��ucG m�ork himself or
.. .., tAroagb hir-o employees, provided fbat such�em-
Groding prnvements�ore not intxnded nr offered�nr sale. If,
hou•eaer,tl e buildinq nr improvement is sold urtfiis one
Geologicol " t'ear nf completinn, the ounervbuilder ud!!bax�e dhe
. burden nf prnvrn,y thut he drd mnt dui1J or rmQr�ir�e frir
Pedestrian Pwtection tbe purpose nf xule/.
�Fence)(Canopy) ' � � � r� I,os awner of�he property,om exdusively coMroc-
. � ring wiih licensed contracrors to consfrucr rhe projecf(Sec.
Special Inspection " � ' 7044J Busrnes.e and Pro(es.cinns Codc: The Contractnr's
(Conc.)(Masonry)(Welding) "License I,aw dne.��nnt applS'to ax oa�ner of pr�erdy u•5�
fiuilJs or rmprnz•es 1/�eroon,and u$o rnxtracts f r sucl.r
Lot Drainage "� . , � . p'rojects u�ith u. cnntructor/sJ liceresad pursuant tn the
� Cnnlydclnr'.c l,icense Lau�J.
Parking � � - � '
.] 1 om exempt under Sec. ,6.8P.C.for ihis
reason
Date Owner
Approvals Dafe inapector's Signa}ura �
. INSPECTOR'S NOTES
.... ..... ..... ... . .
Location—
(Setback&Yards) -
Foundations
Slab
Frome
Energy Insulotlon '
La�h/Drywol I��
Interior
Lo1h-Exterior
HouseNumber-- � - � .
Corred 8 Posted .
Final--
Enter on Front �