HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (60) WORKERS'COMPENSATION DECLARATION �- . -� "-�'`�- ' .. �
I hereby of{irm ihat I have a certificofe af consent fo self APPLICATION FOR� �UILDING PERMIT
insure,or a certiflcote of Workers'Compensation Insurance,
or a certified copy thereof(Sec.3800,Lab.C) COUNTY OF LOS ANGELES BLlILDING AND SAFETY
Policy No. Company � � .. . �,
� Certified copy is he�eby furnished. FOR APPL(CANT TO FILL IN '" ' " '- BuaoiN� �., - - "��`�.,
ADDRESS � �I� �-�. �n�...,'.-
� Certified capy is filed with the county bu�ilding inspeo- auiLowG _ - •�- � � � -
tion deparlment. ADDRE55
Date Appllmnt ❑iY ' ' LF IOCAIIiv .
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. � NEAREST
COMPENSATION INSURANCE SIZE OF iOT NOW ON LOT CR055 5T.
(This section need not be completed if the permir is for one ASSESSOR
hundred doilars($100)or less.J TRACT BLOCK LDT NO. MAP gOOK PAGE PARCEL
TE�. ❑SE ZDNE NJ+P ./. Y
I cenify ihat i ihe performan<e of the work for which thls OWNER NO. NO. p,
permit is issued,I shall no�employ any person in any manner qDDRE55, ' � CONDITIONS �
so as 10 become su6lect to the Workers'Compensation Laws.
W
. � ... - ,. . ..�'...,'' .., .. CI7V ' ZIP : �
Date ' ' :'� � Applimnf ,�.' .:�,�� . ' '�- ' .�.� LL
ARCHITECT DR TE�� DISTRICT GROUP TYPE FIRE PROCESSE�BY
NOTICE TO APPLICANT: If, ofter making this Certifimie of ENGINEER N�� CONSL-:.-�'"'" ZO �
Exemption, you should become subjeU to ihe Workers' , -� .
Compensation provisions of the labor Code,you musf forth- ADDRE55 E`t' �� ` `; j �
ith comply with such provisions or this permit shall be - - -
deemed revoked. , . TE�� STATISTICAL C!ASSIFICATION ~ APT. C DO. �
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLA55 NO. ' � DWELL.�NITS �
W
I hereoy affirm that I am licensed under pro�lsions of Chapter 9 ADORESS � ' � NO::� ' ' SEWER MAP � � ��� F
(commencing with Section 7000�of Division 3 of ihe Business and LIC.
Professions Code,and my license is in full torce and effe<t CiTV CLASS � gK �� VALIDATION
.. SQ.FT. NO.OF NO.OF CHECK
License Number ' Lic.Class SIZE STORIES � FAMILIES ONE .
� - VALUATION
Coniractor �. ' ' Dafe � DESCRIPTION Of WORK Ap O S»;�,..-�-""!'y
❑I am exempt under$ec. , , �. ..-
. ALTER � ;.G�`-'f`
B.&P.C.for this reason " - REPAiR ❑ S �' � ��� � o-q,.,',c ������
J.�!.:
Date; USE OF DEMOI �' ' r'--
EXISTING BLDG. '�f n,n`£�; �;.
Signafure � „'-.'.:�. '� - . . APPLICANT TEL FSNAL ' .� g ,. '.,.•.
OWNER-BUILDER DECLARATION PRIN7) NO. ppTE i A1,^.°.�. .'�:1 t„
I hereby affirm that I am exempt from the Coniractor's License . ,. . , , . , . ��,i.���,, e.N F,�
Law for ihe following reason($e<fion 7031.5, Business and ADDRE55. FINAL .t g ,- _,_
Professions Code): P ESEN7 .._ " � �' •' ' � ��' BY
❑ BUILDING " � - . .
I, as owner of the properfy, or my employees with ADDRE55 �l�' ��f'
wages as iheir sole compensation,will do ihe work and , `?'� ". .. ��
ihe structure is noi intended or offered for sole(Sec�ion �OCALiTv _
7044,Business ond Professions Code). MOVING TEL ' .. . , `�!:,
� I,os owner of the properfy,om ezclusively coniracting CONTRACTOR NO. , � 4 `
wi�h licensed controctors to construct the proiect(Sec- ���_ ���'-
tion 7044,Business and Professions Code). ADDRESS
REQUIREO 70TAL SETBACK FR %I L �.'-F+� .` .. •
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.LINE �^/iDTH
I hereby affirm�hat there is a construction lending agency for fRONT � <��ti�?
the performance of the work for which ihis permit is issued P.!. ' � ' �
(Sec.3097,Civ.C.). SIDE -c.♦ :;
P.L. . . .. � .
D Lender's Nar�s ;�� . iDMA Ref.# ' fi�.$�`�•�:�F:�.
� Lender's Address P.0 Fee 5 .,. -� 7e!mi'Fee � � , . . s... :
_ G.4 4:;
'�' I certify thot I have read this applimtion pnd stote fhot fhe � '� Issoance Fee ' ' IDMA P.'C# �,�s:,o. :�•(
¢ above mformation is correct.I agree lo comply with all County Investigation Fee ` '' `� `
� ordinonces and Sime laws relating to building constr�cfion, Toral Fee � f LDMA Perm.#
�
and hereby aufhorize rep�esentotives of this County to enter
a upon the a6ove-mentioned property for inspection purposes. .. , . ..,.,..:.� ._...°..•:--...• .� ..-.•`.::�-�<+r,�._..::....::..:." .... , . .. -
.' -� . , � - � ��� . '�� � SEE REYERSE FOR EXPLANATORY LANGUAGE
. �S�gna�ure of Appl�cani or Agem ,�Dar¢ '��