HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (68) WORKERS'COMPENSATION DECLARATION ^
I hereby affirm ihat I have a certifimfe of consenl fo self APPLICATION FOR BUILDING PERMIT �L�
insure,or a certifimte of Workers'Compensation Insurance,
or a certified copy ihereof(Sec.3800,Lab.C.) COUNTY OF lOS ANGELES BUILDING ANO SAFETY
PalicyNo.��' �Compony '. . " .r�.� - � .
.�.... ;._..... . . :
' " .... BUILDINC� `7 � ., .-.. , j „ ...
CerriFied copy is hereby fumished t� FOR APPLICANTTO'FILL IN
,r-'( Cerrified co Is filed wlth the mu t buildin i s eo ADDRESS �� �` G�� }...�i i` - ,;'�,�,�..'.,
py n y g n p BUILDING
U tion deparfm ft. ADDRE55
Date - ' APPlimnt '� � , � - QiY ZIP LOCAIITv
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS.�� NEARE57
COMPENSATION WSURANCE SZE OF LOT NOW ON LO7 CRO55 57.
(This section need not 6e wmpleted if the permif is for one ASSESSOR
hundred dollars(5100)or less.) TRACT BLOCK LOT NO. NWP BOOK PAGE PARCEL r
TEL. USE ZONE MAP ' d
I certify that in ihe perfoimance of the work for which ihis OWNEe NO. pp • ' , - �
permit is issued,I shall not employ any person in any monner 1 J SPECIAL
so as to become subject fo ihe Workers'Compensafian Laws. ADDRE55 CONDITIONS �
CITV ZIP LL
Date Applicant �
NOTICE TO APPLICANT: If, after making Ihis Certificale of ARCHITECT OR TE�� DISTRICT GROUP T1'PE FIRE PROCESSED BY.
Exemption, you 5hould be<ome SubjeCt to 1he Workers' ENGINEER ND. CONST. ZONE �
Compensafion provisions of ihe Labor Code,you must forth- qDORESS ' ` � o
wifh comply with wch provisions or ihis permit shall be TE� . ' �
deemed revoked. STATISTICAL CL4551FICATION APT. CONDO.
CONTRACTOR NO. �
LICENSED CONTRACTORS DECLARATION �i�. CtA55 NO. i DWELL UNITS F-
I hereby affirm that I am licensed under provisions of Chopier 9 ADDRE55 NO. .
(co cing with Section 7000)of Division 3 of the Business and �i� � SEWER MAP
Profe sions Code,and my license is in full force and effect. CiTv C�A55 BK � VALIDATION
, Sq.FT. NO.OF NO.OF CNECK
Li<ense Number Lic.Class SIZE STORIES FAMI�IES ONE .
VALUATION
Coniractor Dafe �ESCRIPTION OF WORK NEW Q .;J�j�1,
; _....-..^^..`.°""'_`.,-. ' �'-':.
ADD ,-^''" ' ,:. 4�z,�s w S,::
❑I am ezempt under Sec. � '",�' �
ALTER :�,.�`"*,f�..-"'"". .�:•�'°',o'.^�`,�n I.%
8.8P.C.for fhis reason REPAIR ❑ f �-y�� ��
USE OF . j ' . DEMOL ❑ ��'��';•.�
Date: E%ISTING BLDG. "''�� ����'
Signature APPLICANT � TEL. - FINAL �R:k.S':"�.�:.t
OWNER-BUILDER�ECLARATION PRINT) �`O. DATE
I hereby affirm that I am exempt from ihe Contrqctor's License
Law for the following reason(Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENi � -� - � BY
� � 6111L�ING .
I, as owner af the properly, or my employees with ADDRE55
� , , wages as iheir sole mmpensation,will do hhe work and ,
the structure is not intended ar offered for sale{Secrion LOCau7Y
7044,Business and Professions Code). MOVING TEL.
� I,as owner of the property,om ezcl�sively wniracling CONTRACiOR NO.
wiih licensed contrpdors to conshu<t the project(Seo- qDDRE55
tion 7p44,Business and Professions Code).
CONSTRUCTION LENDING AGENCY REQUIRED TOTAI SET6ACK FROM EXIST.
SET BACK �ARD HWY PROP.LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT -
the performance of ihe work For which this permit is issued P.�. � - •v �
(Sec.3097,Civ.C.). SIDE Y,;�'u�s,,a c 1�
P.L
Lender's Nome � � LDMA Ref.M 't�~'������"'�"
- Lender's Address P.0 Fee 5 Permi�Fee a.Q;0:;Y�,7 R
I ertify ihot I have read this applimtion and s}ate thot the ` Issuance Fee LDMA P/C q � . ��' "°=�
a6ove information is mrrect.I agree to comply with all Counry Invesri9arion Fee � �y��M�x����'
� ordinances ond Stare laws reloting to building construction, To�al Fee I.DM.4 Ferm.H
and hereby outhorize represeninfives of this County ro enter .
�`
mupon the above-meMioned prop�rty for inspection purposes. � .-......-.-......�.,--.......,,..,,.-�.....,.,...,.:...::..._�,:.. ..:. ._, . .
a � ' '� ' $EE REVERSE FOR E%PLANATORY LANGUAGE �
� Siqnalure af Applicont or�Agem� " ..'Dote - � � �"
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