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Home My WebLink About1155 SOUTH DIAMOND BAR BLVD (85) WORKERS'COMPENSATION DECLARATION � �VL�'n.."� r�i� /�'� I hereby affirm ihaf I haae o cerfificae of consen�to self APPLICATION FOR BUILDING PERMIT � insure,or a certificate of Workers'Compensation Insuranre, or a certified copy fhereo4(Sec.3600,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Company Ceriified copy is hereby furnished. BUIIDING FOR APPLICANT TO FILL IN ADDRE55 /1�5 ',%-��,.�,,.,�(, (�yz� � Certified copy is filed wiih the covnty building inspec- gUitDiNG ` �] � �q{� / tion departmenl. ADDRE55 �7 D! /�1�� .`�- CNW `'� Date Applicant CITv (Y\Q�� (47��/'L ��Z�p j �OCALITY CERTIFICATE OF EXEMPTION FROM WORKER$' � NO.OF BLDGS- NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CRQSS ST. (This se<tion need no1 be completed if the permit is for one TRACt 6LOCK LO7 NO. �ESSOR hundred dollars($100)or less.) -�p�A �{-�yp ,��7 �/ p MAP BOOK PAGE PARCEL OWNER'�/Y1Y`� SJ�J�i'�+�VFV' Np�TI`t-O�F• ZONE �P z I certify that in ihe performanre of the work for which this �` p /`� NO. f�� ,,/�.1 pe�mit is issued,I shall not empl any person in any manner qDORESS � L p�i� ��iF/ �F-- (,,,+� SPECIAL � so as to become subject to the o ers'Com ns tion Laws. A CONDITIONS � {Y': CIT [ /"r� ZIP ��{vS� � '�,Dafe � • Applic t ARCHITECTOR 'n TEL. � NOTI O A PLICANT: If, fte makin is erlifica�e of — DISTRIC7 GROUP 7YPE FIRE PROCESSED BV p � ENGIlJEER ' �7 ' NO. Exemption, you should b co e s�bj to the Workers' � ` , CONS7 ZONE �--. Compensation provisions e Labor e,you must forth- ADDRE55 4� ._"� �� with comply wifh such provisions this permit shall be W deemed revoked. -�Jy>�,,� TE�� %�- TATISTI�AL C1A551FICATION APT. CONDO. � CONTRACTOR� Lt,y sSUt(/��P�p� � LICENSED CONTRACTORS DECLARATION ��C p.-� CLA55 NO. DWELL.UNITS . I hereby aff�rm iha�I am licensed onder provisions of Chapter 9 qoPRe55 � C�'C�y�,�. P/}Ik NO.p /� (cammencing with Section 7000)of Division 3 of�he Business and *� �� SEWER MAV Professions Code,and my license is in full force and effect. CI7Y '1�'/VV b�'�� 7� U'� CLq55 VALIDATION SQ.FT.q-�� NO.OF NO.Of CHECK BK' �'' License Number Lic.Class SIZE O`-' STORIES FAMIUES ONE �I VALUAjjON DESCRIPi�ON OF WORK NEv✓ s �/ �y,� C❑ontractor Dafe n �O ADD ❑ , I am exemp�under Sea j_� ALTER � B.&P.C.for fhis reason REPAIR g Date: USE OP t4 �EMOL ❑ -=O C'�'4 A E%ISTING BLDG. Signafure APPLI�P,NT - TE. ,..�j °�j.��j�'� PRINT� NO. �lCYGSO FINAL OWNER-Bl11LDER DECLARATICN DATE r�?� I hereby affirm thot I am exempt from the Confractor's License Law for the following reason(Section 7031:5, 6usiness ond AODRES$ FINAI q Pro4essions CodeJ: pRE N By +�-�'�� BUILDING �Jf�If� �,,,, I, as owner of ihe propery, or my employees wifh ADDRE55 � d wages as their sole compensation,will do the work and � the siruclu/e is not intended ar offered for sale(Secfion LOCAI.I7Y 7D44,Business and Professions Code). MOViNG TEI. � I,Qs owner of the property,am ezclusively mniracting ��NTRAGTOR NO. p � � with licensed coMractors to consrruU fhe project(Sec- qDDRESS ,eF�N tion 7044,Business and Professians Cod�). � /� _�� REqUIRED TOTAL SETBACK Fft M l�� ' CONSiRUCTION LENDING AGENCY SEf BACK YARD HWY PROP.LINE N/iOTH /� Z�S�I I hereby affirm thor there is a conslruaion lending agenc for ` ihe performance of the work for which this permi�is is ued PRONT �� S� ($ec 3097,Civ.C.). SIDE P.L. lendei s Name L�MA Ref.p � Lender's Address P.0 Pee$ Permir Fee ' 3 I certify that I have read this application and state that the Iss�ance Fee IAMA P/C# obove informotion is correct.I agree to comply with oll County inves��gor�on Fee ordinances and Stote laws relating to building construction, torol Fee LDMn Perm.# cnd hereby authorize representatives of this Coun�y to enter on ihe abov - entioned properry far inspacfion purposes. � � -t � SEE REVERSE FOR E%PLANAiORY LANGUAG£ Signo App�cant or gent Dote�/ ,._�__ __..__.._.._.__..._.4.�._�e_._. _.a _.._�_.�._...._..._._...__._.e.u_._,__� ..M.__._.�.w_._._.___ ., . . ., , _ � - -, „-�,,. ;� = �. , ., ,__..._. ....._�_.__. .�,_.._.____, ..�.._�.,_._......_._._ ._., _._..��_ _._. ..._� w__..�__.. , ..�_.._. __u.�___._..,_�__ _.. , , ;_ , �_,.a,�,a , ... ., ._ . - - . . — � ...,.,., �---. _ _ ..__...___ __ __--._. . _..._ . _ i _ , '. � :. . , ;4 ..:u _ _.__ _._.,._,. _ — . _.._ ,_.__ ..._, ,,�.._......._..,_.._.. ..__m.---- ...-- -.. ..._,.____. _...._,._ ,.4 . r , ,. , � , . , � _ _....__ . .___ _. ._. __ �_.. _ _. _ . ._ _. ,..,_..---__,. .__.. __,...--.. ___.___ __ __ ..___.___.-- -.. _ , . . . � ; � f ,,.....,....�.....�,__.......�».._....._....._�.-..._.....� ,._........:..........�......�.A..me.......�-_"___....,___"__"_...._`__".._.__ ,. ._...."__....._.._ ...... .r. , ..t. .' 1,. . . ,.. . .,ri - .. ;. ,�i. .. ._ ...._"'_."___"""__.. ! 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