HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (91) _ - .__ __. - -- - -
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"' JMP�?ISATION�DECLdRA"I`ION . . �. � .�..... � ..,�� .. L�
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. . .. .. . . . . _ . _ .�
i ,_ _ teof Workes'�Compensatonslnsuron eIf A�P�P1r�CATION FOR ���F�I���LD�I�NG PERMII`
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or a certitiea�opy rhereof(Sec 3600,Lob.C.) � -� - �� �-, . .... .
COUNTY OF LOS ANGELES BUI�.UING AND SAFETY
P❑olicy No. Company .•.. . -... ...--
Certified copy is he�eby furnished. FOR APPLICANT TO FILL IN BUILDING • ��, m ^ r
ADDRE55
� Certified copy is filed wifh the�county building�inspec-� guuoiNG 1 _ -- {�� �
fion departmeM. ADDRE55 i ^ � (� p�.��
Date Applicant QTY ( - ZiP LOCALITY �
CERTIFICATE OF EXEMPTION FROM VJ6RKERS' - � No.oF atocs. NEAREST
-COMPENSATION INSURANCE � -'� SIZE OF LO7 NOW ON LO7 CRO55 ST.
(This sec�ian need not be completed if ihe permit is for one ASSESSOR
hundred doliprs($100�or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
J TE�" USE ZONE NOP 3�/,
OWNER CLAs Q DP �l NO. - J� j��- y��
I certity thdt in the performance of the work foi which this , }
permif is issued,I shall not employ any person in any ma�ner ADDRESS ,� � N�l �-M SPECIAL � d
so as fo become subject to fhe Workers'Compensafion aws.� CON�ITIONS . O
o�,fe � r APPlicanl ��,� arr MlSSI� z�P 1 �� m
��(NOTIC TO APP�ICANT: If, after making this Certificate of ARCHITfCi OR TEL �
Exemption, you should become subject to ihe Workers'
ENGINEER NO. DISTRICT GROUP TVPE FIRE PROCESSED BY
Compensafion provisions of the Lpbor Code,you musf forfh- qDDRE55 j� COI�.r"� 1Z0� �
V �1
w�ih comply ��h such pro��s�ons or rhis pe�m�� sholl be - � � re�.BL S7ATISTICAL an55�i�ON APT. C oo.' Z
deemed revoked. CONTRACTOR � � NO. �'
LICENSED CONTRACTORS DECLARATION �i� Q c�a55 NO. d � DWELL.UNITS
I hereby affirm thot I am licensed under provisions of Chapter 9 AD�RESS � N /3�
(commencing wifh Section 700D)of Division 3 of fhe Business and p,��. ,G ��� �p SEWER MAP
Professions Code,and my license is in full force and effect. UTY A 1 L�`y`L� C1A55 /J BK � VALIDATION -
� $q.fi. NO.OF / NO.OF CHECK
License Number G 3 ���u<.c�ass.� size O sloRies ` FAMIUES oNe
vawnnoN
(�� �L DESCRIPTION OF WORK 1 -NEW
Conirp[tor W`�C llrnl� Dpte� ADD � s'
�I om exempt under Sec. �"�-'s t"11�'�����' q�TER G'1 � , �3 9 C�3 P.
B.&P.C.fo�rhrs reason � . . . e�+ 'T� r4.uPtG (J'VT REPAIR ❑ S �i��-�- �;a e a o G�
USE OF
f� ate:' EXISTING BLDG. �EMOL ❑
S'anafure ��I�./'. APPLICANT�`� TEL. FINAL p � � °G.�i C C
OWNER-BUILDER DECLARATION �RiNT)w N�. - DATE ���6 �
I hereby affirm that I am exempt from ihe Caniractor's License qDDRE55 l FINAL ry ry �C J�U C`
Law for ihe following reason(Secfion 7031.5, Business and • /
Professions Code): PRESENT Dt {�, BY ' / 1 i.�L:'-8 6
� BUILDING l�'^S �,�6 D �L�f� i i�C�.�A
I, as owner of Ihe properly, or my employees with ADDRESS
wages as their sole compensation,wifl do the work and , ; o G m C�
the structure is not in�ended or offered for sale(Section LOCAUTY *�
7D44,8usiness and Professians-Code). - MOviNG TEt. - � � e ;
� I,os owner of fhe properiy,om exclusively con}racting CONTRAC70R NO. i a •C1�L .,
with licensed contradors to construcf the project(Seo- qDDRE55 '� ' �''0 �:�r L es.�
fion 7044,Business and Professions Code).
REQUIRE� TOTAL SETBA K F M
- CONSTRUCTION��LENDING�AGENCY-` -��� � SE7BAGK VARD HWY pROP,LWE WiDTH .. i �J"t5�
I hereby affirm fhat ihere is a consfrucrion lending agency for FRONT
ihe performance of the work for which this permit is issued p.�. �;i C''G C�A
(Sec.3097,Civ.C.J. SIDE
. . _ . . P.L [,�:-¢ o e o�
Lender's Name
" (�(� (g -7� LDMA Re£.N I , ��-U, �
' - P.C.Fee$ VV Permit Fee �d- / �
- Lender's Address f (
I.cerfify thot I have read fhis applimtion ond state thal ihe . Issuance Pee { U "3� LDMA G/C B , ` ` � ''� �'•�-`��z
< o6ave informarion is correct.I agree to comply with pll Counry Inves+igo�ion Fee � •-�
� ordinances and Stpte_laws relating to building construction, , io�al Fee _'o�/� LOMA Perm.k °� �'�'���'
and hereby authorize representatives of this County to enier
m pon the above-mentioned roperiy for spectian purposes.
: �r������ ��� _ _
SEE REVERSE FOR EXiLANATORY LANGUAGE
Signot�r f Applimnt or Agent Dat - ' ' �'�
A
�
+nas�.n.n.s,�. . �+.��....- -'�
� PlANS TO APPIICANT INSPECTOR'S NOTES OW1�I�:R-BUII.DF.R-DEC
, . . „ , _ I hereby affirm that I am�exempi
To: Refurned License Law for the following r i)
� Approved Business unJ Professions Code:Any n.r�. w..tN u�bicb
No. Dafe No. Dafe � � - rcyuires a[�ermrt to rnnstrssct,alter,rmpmre,demadisb,
_ .. . . . .._ . nr repair an}�seructurc,prior to its issuance,also reyazires
� _ � ihe opplic�at fnr �ch perneit to�'le a signed statement
. _ t!at be is liceresed pursuaret tn tbe provisinns o/tbe Con-
. _ , tractor's License Luw(CI apter 9J(commencing:cith Sec-
. tinn 7000J<J1A'vision 3 rf 15e Bvsiness and Professinns
, � , . . CodeJ or tGaa Ge is exempt tberefrom and the b¢sisfnr tbe
, udlc,�ed exempNon.Any vioJallon of Secaron 703f.j hy
Required Dafe Heceived uny applicunt fnru permit.eubjecds tfie applicant io a civrl
Approvols or ApproJed penalty of not mnre dhan/ive bundred doTlars($500/.J:
Yes No ;
. �_ I,as owner af the property,or my emp�oyees with
Woter Certifimre � . . . � . , � _ . � ' � -��-� . -„ �- wages as�heh sole compensalion,will do the work,and
� ihe struciure is not intended or offered for sale(Sec.7044)
Heallh Depanment . . ' ' • --. .- . . -"-` , Bu.riness und Profe.vsrnn.r CaJe:The Contractbr's License
I.au��dnes xot�1��ro an owner of propc�rty wfia burJds
Fire Depanment � ^- � -���-�- �- �� ����� � � � or improve.c aherenre,and u.�ho does suc5 work bimself nr
� tlrougb hi.v oran empfoyees, provrded tbat such.,im-
Grading �� � �� prnr.ements are not intended or offered for sale. If,
hnwr<�er,dhe Auildixg or irapror:emettt is sald u;itbix nne
Geologicol . y¢ar o(mmpletinn, tGe ou,�n¢wHuilder will bae�e tbe
. . _ .,. , � _ � burden nj prnving lhat fie did not build or imprnve jor
Pedestnan Protectlon � . tbe pur(�ose nj.��aleJ.
(Fence)(Canopy) � � ' " � ' ' � �-� " - - � C I,as owner of the properiy,am ezdusively contrar
�� -� . � ting w�fh licensed controctors b construct the project(Sec.
Special Inspection � - 70441 9usiness uxd Prnjessian.��Code:Tbe Coxiraclor's
�Conc.)(Mosonry)(Welding) � � . l.icersse Lam does noa applV tn an owner oJrmpertv u�Fo
� " huilds nr iinprnt�es ebereove,and u�bo contracts for such
Lot Drainage . . , -' , � � � hrojects u�i6h a co�trucepr(.��J/iceresed pursuant fo tbe
�� . Con6rador's License Lau�/.
Parking � . .` " . . . - ,
L I am exempl under$e<. ,B.BP.C.for this
� reason
� � . Date Owner
, ... .. . .� .. ,'N. . ...... �. .,.._. -...
Approvals Dote Inspecfor's Signot�re .. . ��-_ . SPECTOR'S NOTES
Lowtion-- � � .� . ,•...
(Setback&Vards) • � • '- �� � � � �
Foundations . . , . . . �. ., .. ,, .. � .... ...". .,
Slab ....�..:. . ... ......�,.. .:.
Frame !`: ] .....`7 1 J-�>�� l�.- _ . . . .. . .. . .
!
Energy Insulolion �,`_.. f. . - � . . . .� .,. . ... .... �..�..�
:�
LathiDrywall- . %. �` . _.... .. ......... . . . . ...
In7erior I �,'�-'�;7 J� -� .. , . ..
. _,r-. . . . . _... -.- -._'_.
Lath�-�-Exterior
House Number-- � � " " � "
Correct 8 Posied
Final—.. . . . ,_ , . .
Enter on Front