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HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (76) , _ _............_.... _ WORKERS'COMPENSATION�ECLARAiION ' ' /� - � /�� r� ■ I hereby affirm that I hove a certificote of consen�to self � /�PPL�( A�'o� ■ o� Yu�����V ■ `�Ii\' ■ � insure,or a certifim5e of Workers'Compensa�ion insu�ance, /"L s ro^ or o certified copy ihereof(Sec.3800,Lab.C.) ' � �y-�'p�c�,., �,S7�h� C�r„�.faFi✓Ssfnv� COUNTY OF LOS ANGELES BUILDING AND SAPETY Polity No.y�/1.�vCompony � Cen'rfied copy is hereby fumished. 1 NS�2sy+lc%F-.r` fOR APPLICANT TO FILL IN auuoirvc ���5, /�M(IND gLfy') #' ADDRE55 f� Certified copy is filed with the county building inspec- gUiLDiNG JA� rion department. AooRE55 %/ f} k3r..1�D LE/��jN� Da1e`���'- Applim�t�L Jt2�r.�'fa""G�✓�"J C�ir / ZIP �OCnurr CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF B�DGS. NEAREST COMPENSATION INSURANCE SiZE OF t07 NOw ON LOT CRO55 57. (ihis settion need not 6e complated if ihe permit is for one ASSESSOR � hundred doilors�$100)or less.) TRAC7 BIOIX LDT NO. ,�WP BOOK PAGE PARCEL TE� � USE ZONE MAP - - I certify thal in 1he performonce of fhe work for which this OWNER NO. - � permit is issued,I shall no�employ any person in ony monner SPEC�AL � so az to become subjecl to the Workeri Compensation Lows. ADDRE55 CONDITIDNS a �ote����" Applicont�P'��+-�'•�_,��- ��`-'�-' CITY ZIP � IJOTlCE TO APPLICANT: If, after making ihis Cerfificafe of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY � Exemp°ion, you should become subject fo fhe Workers' ENGWEER NO. CONST. ZONF (�, U Compeasation provisions of the Labor Code,you must forth- ADDRE55 '� -- �G�,��Q ith comply with such provisians or this permit sha71 be -i�y ,� � Y ` a.� TEL.. STATISIICAL CI.ASSIFIC ON APT. CONDO. (n deemed revoked. CONTRACTOR - y�� _f/ ND. g'/ '�3 S � LICENSED CON7RACTORS DECLARATION �.# 11C. CLA55 NO. DWELL UNi7S �- I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS {. p NO.�7� (commencing with Se<tion 7000)of Division 3 o41he Business and _���. `'E�R�P - Professions Code,and my license is in full force and effect. GTv r' �� M '->A CtA55 C- � aK � VALIDAYION �y SQ.FT. NO.OF ' NO.OF CNECK License Number����y�Lic Glas Cs -�/S 52E STORIES fAMILIES ONE VAWATION � r-^, ��, S'!(NI �./s_p.7 DESCRIPTION OF WORK A D ❑ s ����� U� ConrracrorL�-L. i-L./� pate xs r� �I om ezemp5 under Sec. fNS! '� N � . , ALTER B.&P.C.for this reason �✓1 �� �F� N e ��REPAIR � s ���&�A Date: USE OF � DEMOL e s E%ISTING 6LDG. �i° 'C J Signature APGUCANT p TEL.�� FINAL ...,.. . OWNER-BUILDER bECLARATION IPRINT S V. p NO. DATE � a m 2�.O O 1 here6y affirm Ihat I om ezempt from the Comractar's License � � Low for the following reoson(Section 7031.5,Business and ADDRE55 � �"Z_� kt� FINAL m ° "2�.Q�1� Professio�s Code): euuo Nc '� � sy D 3.1 6'-8'] � I, os owner of the proparty, or my employees with ADDRESS wages as their sole tompensafion,will do the work and �OCAUTY � the stroct�re is noi intended or offered for sole(Sedion 7044,Business ond Professions Code). MOVING 7EL. � � I,as owner of the property,am exclusively conteaUing CONTRACTOR NO. j PPP111 {y�' wilh licensed caMractors�o consfruct the projecf(Sec- � --- � .y� // £� � ADDRE55 tion 7044.Business and Professions Code). „e'1 � REOUIRED TO7AL SETdAC � i7/� CONSTRUGTION LEND�NG AGENCY SEi 6nCK YARD Hwv p�p ��NE wiDiti �� I hereby affirm that there is a construction lending ogency for FRONT �he performance of�he work for which�his permit is issued R�. � z 7 1 5,8 A (Sec.3097,Civ.C.j. 5ioE P.L. 1}� . . • ¢j Lende�s Nome [�(�,. ' IDMA Ref.M � � �3��5 m Lender's Address P.C.Fee S �-T.� Perm�+Fee �� � 3 a e s I ceniiy fhat 1 have read this applica�ion ond stote rhpt the isauance Fee � w� L�MA P/C N 6 S 6.7 5:.o above informotion is correa.I agree fo comply wilh all County In�asligafion Fee ��G� ,.0 8 7 ordinances and Stote laws reloiing to boilding construction, Total Fee tOMA Perm.A � and hereby auvhorize representatives of this County to enter a upon tF�e above-mentioned p�operry fo�inspecfion pu�poses. � -' --�'-�- � - - ' - / . ., . . . -:, ' � . 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