HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (69) WORKERS'COMPENSA7ION DECLARATION �
I hereby aPfirm thaf I hove a cenificote of ronsenf fo self APPLICATION FQR BUILDING PERMIT �
insure,or o cei��ficote of Workers'Compensation Insurance,
� or o certified cooy thereof(Sec.3800,Lob.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
' PalicyNa. =• Y �� - Coirlpany
, Q Certif�ed copy�s hereby fum�shed. � FOR APPLICANT TO�FILL IN �' �-" � auuow�
ADDRESS
, � Certified copy is filed with the coon�y buiiding inspeo- gUiIDiNG • � � � ' ' ' ' � "� � "'
tion depariment. AD�RE55
D6te Applicont CITY ZiP LOCAUTY � '
` CERTIFICATE OF EXEMPTION FROM WORKERS' �� �" �NO.OF BLDGS. NEARESi
COMPENSATION INSURANCE 5¢E OF�OT NOw ON LOT CRo55 Si.
(This sec7ion need not be completed if the permit is for pne 7RACT BLOIX LOT NO. iyyP58pOK � PAGE PARCEL O..
hundred dollars($100)or less.)
OWNER NO. USE ZONE NWP �
- I certify that in the performance of ihe work for whith this ._ . . NO.
permit is issued,I shall not employ any person in any manner SPECIAL � " ' �` J
so as ta 6ecome subject to ihe Workers'Compensafion Laws. P�DDRESS GONDITIONS LL
CITY Z�P �i-
Date Applicant �
ARCHITEG7 OR TE� DISTRICT GROUP NPE FIRE PROCESSED BV
NOTICE TO APPLICANT: If, after making this Certi4icare of ENGINEER NO� [pry$7, ZppJE �
. Exemption, you should become subject to the Wvrkers'
Compensotion provisions of the Lqbor Code,you musf forth- qDDRE55 -"` "e ` - �..
with comply with such provisions or fhis permit shall be TEL STATISTICAL QASSIFICATION � � APY,�•. �CO DO. �
. deemed revoked. CONTRACTOR ' NO. �" �
� UCENSED CONTRACTORS DECLARATION ` � `" LIC. ` " CLA55 NO._ -_ ' DWELL UNITS
I hereby af4irm thpt 1 am licensed under provisions of Chapter 9 ADDRESS ' � .NO. ' $EWER MAP
� (commencing with Seciion 7000)of Division 3 of ihe Business and ` " ' �� " " - � �i�, " >
Professions Code,and my license is in full fotte and effetl. CIiY - . CLA55 �,' BK � YALIDATION
5�.FT.� NO.OF NO.OF f�CHECI(
LicenSeNumber Lic.Class SIZE �� STORIES .FAMIl1E5 ONE
~ � � VALUATION
� � � DESCRIPTIpN OF WORK "' � �-
C❑ontrattor . -, . . '�ate � _ ... .:... LL A D Q s , .. .
I
I am exempt under Sec.
. AITER � S ,::.C:.:i fa,`>'.�`.
8.8P.C.for fhis reason ' • REPAIR � . �
e a n e�
Date: EX ST�ING BLDG. � DEMOL l'�" �"�' '�
$ignoture APPLICAN7 TEL FINAL i'e'�R'6-'t�`U
- OWNER-BUILDER DECLARATION PRiNT NO. -� DATE c'-�;�+
I hereby affirm�hat I om exempt from the CoMractar's License z�'.�'�-�":"4:�`
Law for ihe following reason(Section 7031.5, Business and ADDRE55 FINAL `,s? C�.M1'�j f,
Professions Code)� � BY �' � " ""
� ❑ BUILDING
�, as owner of the propeny, or my employees wiih AO�RE55
wages as�heir sole compensation,will do the work and �OCALITY ,
� �he structure is not intended or offered for sale(Section
7044,Business and Professions Code). MOVING iEl. -
� I,as owner of ihe properfy,am exclusively contracting CONTRACTOR NO.
with licensed cantractors to construcllhe project($ec- qoDRE55
tion 7044,8usiness and Professions Code). .
CONSTRUCTION LENDING AGENCY SE7�BACK �/+RD NWv TOTAPSREQTPPLCNE WIDTH .��7,;;�f. '
�,v�,
. I hereby affirm thae there is a construction lending agency for FRONT � �
ihe performance of the work for which this permi�is issued P.L _ ::a;!��s,k's?
(Sec.3097,Civ.C.). SiDE
% Pl. .l,s�r;.+;`r�f.;
Lender's Name . 4 ,6�4 p��
LDMA Ref.ii �-�✓t�����:��
m P.C.Fee$ � :.d�+ Permil fee Y.� 1 '. . '
� Lender's Address - � .1,�:;,t[`„,;^�;;j
�� I certify that I have read fhis applicalion ond sfate that ihe issovnce Fee '� � LDMA P/C#
_ a6ove information is correct.I ogree to comply with pll Counry in�esaga�ion Fee `��� -
ordin nces and State laws relating to b�ilding construction, Total Fee LDMA Parm.M
and here6y authorize representafives of this County to enter
upon the a6o�e-menfioned property for inspection purposes. � - � � �� � " -" �- � -�' " ' '' � �
SEE REVERSE FOR EXPIANATORY tANGUAGE
n Signaf�re of Appl�cont or Agent Dale �
