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HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (80) _.... _ _..... .._ _ _... _ .__�._ _ . ------- ---- �� . _ WORKERS'COMPENSATION DECLARATION � ,e,or a ce tifica}te of Workenr'Com�pensation Insuran elf APPLICA�'ION� FOR BUILDING PERMiT or o cert'rfied copy rhereo�f},((��ec.3800,Lab.C.) COUNTY OF l05 ANGELES BUILDING AND SAFETY PolicyNo.������LdFnpany-5�l�hr0��n%S�9r7u� . . ,�LJ Certified mpy is haieby 4ornished. FOR APPLICANT TO FILL IN eu�towG HQ J 6Y ' � AOORE55 � Cerrified copy is filed with ihe county building inspec- Bw�DING ;�. tion deparimenf. ADDRE55 �� (�/�/Lt h'� L-Y(� 'p pV � fj- -1Nata Applicaat CiTY (.�� � ZIP LOCALITY �� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF eLDGS. NEAREST � COMPENSA710N WSURANCE SiZE OF lOT NOW ON l0T CROSS SL � �� (This secNon need nm be complated if the permit is for one TRACT eLOCK tOT NO. nAi,�qp BpOK PAGE PaRCEL hundred dollars(a100)or less.� !-� TE� C, OWNER � K��`- `� ND..�//�LZ' USE 20NE OP �� �, � I certify that in the performance of the work fo�which�his , J✓1 SPECIAL C]�f permif is issuad,I shall not employ any person in any manner qDDRE55 C — �-" � CONDITIONS �� ���F.O f"+9 � so as to become subject to the Workers'Compansation laws. OO Dote ApplicoM CITV 21P NOTICE TO APPLICANT: If, afler makin fhis Certificote af ARCHITECTOR TE�. DIS7RICT GROUP NPE FIRE PROCESSED9v O 9 ENGINEER NO. CONST. ZONE F- Exemption, you should become s�bjec� to the Workers' >� s v Compenwtion provisions of�he Labor Cods,you must fanh- qDDRE55 � � � with comply with such provisions or fhis parmit shall be TEL. �i STATISTICAL CtA55iFICA710N AP7. CONDO. N deemed ravaked. CONTRACTOR t�� - J NO. /�.S'-' Z LICENSED CONTRACTORS DECLARATION ���. CLASS NO.�DWELI.UNITS I hereby affirm that I am licensed under provisions of Chapler 9 A�DRESS NO. ''t SEWER MAP (commencing with Section 7000}of Oivision 3 of�he Business and liC. Professions Code,and my license is in f�ll force ond effec�. CIiY �?'.iKr9�*tovC CLP.55 �� gK � VALIDATION �,` 5�.F7. NO.OF NO.OF CHECK LicenseNumber'r 7��L�� Lia Class ���-� SIZE � STORIES FAMILIES ONE I VALUATION Contrac7or Z�f'Y�r." i/ S�G Dare -S���-���7 DESCRiPTION OF WORK f^ � A� ❑ � r '�� ��� ❑1 am exempt under Sec. /fv' U'N'G � - ❑ , �rp�b.��i 1�a�'t. ALTER 8.&P.C.for this reason L��" _ - !� !/�`� �'� ' REPAIR ❑ ; j�e e m a�3 USE OF �fe' EXISTING BL�G. �E�� � I ° �G.�i,G O Signoture APPlICANT LFL �j_` FINAL q OWNER-BUiLDER DECLARATION �PR�Ni TE 1' O. !'F� DATE %(,�Z'�(} ° ` '��,C G'�cr`-� I hereby affirm thaf I am axempt from 1he Contractor's License qppRESS FINAL �+�,� �J"`�� Low tor the following reason(Section 7031.5, B�siness and Professions Code�� p - BY OBUILDING I, as owner of the properry, or my employees with ADDRE55 wages as iheir sole compensation,will do the work and � ihe struclure is not intended er offered for sale(Seclion IOCALITY 7044,Busi�ess und Grofessions Code). MOVMG TEL. � I,os owner of fhe properfy,om exclusively tont�acling CONTRACTOR NO. with liCenSed Gontroctor5 lo[on5lrutt fhe projeCf(Sec- qDDRE55 tion 7044,Business and Professions Code). � CONSTRUCTION LENDINC>AGENCY SET�BACK YAR� HWY TOTAPROP.pLCNE M WIDTFI 2���O.3 A I hereby affirm thaf there is a consfrudion lending agenty for. FfiONT :j} o s o x e � �he performance of ihe work for which rhis permit is issued 7.i. (Sec.3097,Civ.C.). SIDe � „ ���7� P.L. Lender's Name °° a`3����� n�^ � IDMA Ref.N P.G fee E x�l��' Permit fee � � � �,rj,`{�+-�j`7 Lender's Address � - !cerlify that I have read 9his application and stata fhpf ihe Issuance Fee ! ��NW P/C fl _ above informpiion is torrect.I ogree to comply wilh all County Invesrlgation Fee ordinances and Sfate laws relafing to building consfrucfion, To�ol Fee � - LDMA Perm.# and hereby authorize represenfotives of ihis County to enter upon the above-mentianed properiy for inspection purposes. , �+_��r.a.�v J �e-�32e.."J ��f(^�Z SEE REYERSE FOR EXPLANA70RY LANGUAGR SignoNre of Apq}icvnf o�Agent Dole ,..�........,�.._...m._....�. .a ».._.,«..............�..-.. .»-.m..,....=,.m...nf.._,.,.e..�, ..,�...,, m 'F�-._.._..e_�.�.e._.......�_.. ., P � .I�. .,_ "1 ... . e� F.._ ..... __..-.-..._._..._.....-......�:.«.................:..::.��...P.._.....,�..._a___...o....._,..,.e_.__._...�_.__. �,..........�: .".:..�..._...._... .... . � � .. , . . ..�....,.P.i '�. . � -., ,. ... _._ . . . .... , �i ., �.... .. . . „. � a... . ; ..,,.,..; . .._� . _...--......--- , _... __.._... .,.....---.. _....._.___.__ _.__ _._.... �,.�r.� , ,� , , . . . . -' . ._ _......_ .Ih - � � -.. . .. ,. �a, .. , . , � . . . ,. . ..- —- . - - I - - +- —� —. - , , . . .. _ . . .s . . . . .. . . . , _, �.. �i...... ._�._.__.�_._.__._. 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