HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (92) _. __
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WORKERS'COMPENSATION DECIARATION . � � � '�� �
APPL�CAT�ON.__��R__-��.r�. �y...�...._.�_.,w :..-.. .�. __
I hereby affirm thpt I have a certiiicate of consent to self ���� ����w'� �
insure,or a cerfificate of Warkers'Compensation Insuronce, �Y/
o�a ce�t'rfi�ed��cop..y�the,�reaf(Sec.3800,La C.•)�p- � COUNTY OF LOS ANGELES BUILDING AND$AFETY
Po❑licy No.�Company -C�v ��e..�47 . .. . ._._....... .,,,_�....-:�,....,..._.__ .r..._ .-:._.-,..__._._.-.._._._�.___ ...... _.._..
Cerufied copy is hereby Furnishe� FOR APPLICANT TO FILL IN BU��v�NG � M ��-.
❑ ADDkE55 �`j C Q �� � •
Certified copy is filed wit�i ihe county bullding inspeo- BUItDING n
tion deparlment. ADORESS � S o J `
uDare /����� APPlico�±-���-,�3�`vir clrY � y zIP LOCaLITv� t Ni7 _ Wy`� ^'
5T CERTIFICATE OF EXENIPTIOfJ FROM�NlORKERS'���� NO.OF B�DGS. NEaREST
� � COMPENSATION�INSURANCE SIZE OF LO7 NOW ON lOi CROSS ST. �
(This secfion need not 6e<ompleled if the permit is for one TRACT BLOCK LOT AUE550R� ���
hundred dollars($100)or less.) AMP BOOK PAGE PARCEL
\ TEL � USF ZONE �4P /
OWNER� � NO. `I NO. 1�I'�
I cerlify ihat in the performance of ihe work for whi�h this a
permit is�issoed,I shall nof employ any pe, on in manner �� SPE��A� ����n' -� �
so'as fo became subject fo ihe Worl e�r' omp on Laws. ADDRE55 S ��` CONDITIONS SY
p �._ _� � .Y�.7 CITY ZIP �
Date�e�."'-����e n..,,,�.,� , ��� ARCHITECT OR TEL. . .. ..... �
NOTICE TO�ADPLI`CANT:�If, after making this Certificaie of ENGINEER NO. DISTRICT GROUP NPE FIRE PROCESSED 8Y
Exemption, you should become subiect to fhe Workers' ONST. � ZONE
Compensa�ion provisions of the Labor Code,you must forth- qD�RESS �� \ d
with comply ith such provisions or ihis permit shall be . �
TEI. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONiaqciOR G-/ i�h' O. �h�S"3c5�
LICENSED CONTRACTORS DECLARATION c,pV:TLIC. CLA55 NO. ��DWELL UN�iS
1 hereby afflrm tho7 I om licensed under provisions of Chapter9 ADDRES 'rf�/' /�}('y�{[, �7 NO.�y �
(commencinq with Section 7000)ot Division 3 oF the Business and LIC. ��R�'P
Prafessions Code,ond my license is in full force and effect. CITv CLA55 C 5 gK � VALIDATION
f� r SQ.FT. NO.OF NO.OF CHECK
LiCense Number n"�yl�� Lit.Clpss �'� SIZE SiORIES FAMILIES ONE �%'�i- � !.(j.�}
- �y . VALUATiON, .
. Canirattorpl.-'����J'L-+�S�C��Jafe ��=��•.�� DESCRIPTION OF WORK ( �D s ���/�� �' z. o a e��
�I om exempt under Sec C '� � , 1�o °G`1 V C'
ALTER
,� B.RP-C.for this reason REPAie � $ � � ,�'F n'�;�
� USE OF -' �`
Date: DEMOL
EXISTING BLDG.
� Signafure APP4PRINTI •'x �- � TEL FINAL,.,r �J J � L,�C'��b
OWNER-6UILDER DECLARATION � �' N�"� DATE �G.-`�d � -
I hereby affirm thot I am exemp�from the Controctor's License qDDRE55 �/SS f!b �! FINAt,.....
Law for ihe following reason (Section 7031.5,Business and
Prof2S310n5 COCJEJ: � ' PRESENT BY `.. � �
� BUILDING ,
I, as owner of the praperty, or my employees with ADDRESS
wages as their sole compensation,wili do the work and ,
�he structure is not intended or offered for sale(Seclio� �aAUTY
7044,Business and Professions Code}. MOVING TEI.
� I,as owner of Ihe property,dm exclusively conlracfing CONTRACTOR NO.
with licensed controcrors ro consiruci the project(Sec- qDORE55
fion 7044,Business ond Professions Code). " �- "-`-" � "" ��
REQUIRE� TOTAI SETBAIX FRO X �5 b 9,2 fi
CONSTRUCTION LEN�ING AGENCY � SET BACX YA20 HWY pROP.LINE WIDTH
I hereby affirm that ihere is a consiroction lending agency for FRONT {f e e re � e'
the performance af ihe work for which this permit is issued P.L. ' ' '
(Set.3097,Civ.C.). SIDE + >,3�,�5
_ . P.L.
Lender's Name �'� �3 6.7 5 c�.�
" h LDMA Ref.#
- Lender's Address P.C.fee 5 �CV-�� Permii Fee ,
01,22�g7
I certify that I have read this application and state thm the Issuanre Fee LDMA viC#
abo�e informafion is wrrec�.I agree 10 compiy with all Counly In�esrigoi�o�Fee a
ordinonces ond Stote laws reloting to 6uilding construnion, io�al Fee �} LDMq Perm.N -
and here6y a orize re entotives of this County 10 enter
o upon�he o6 e-menti ed roperty for inspectio^n urpos�s/. �
o L.-� �m�+������}{fa' SEE REVERSE FOR EXPLANATORY LANGUAGE
' Signolure of Applicanr or Agem Dote ' ' "
PLANS TO APPLICANT� '� � INSPECTOR'S NOTES OW"NF..R-BUILDER UECLARATIO\
. , . , , ,,�_„_ . , I hereby afflrm that I om eaempt fiom the Controctor's
To; Returned License Law for the following reason. (Sec. 7031.5)
Approved Husinesn�und Pmfes.nnns Codc:Any city or county wfidcb
No. Dafe No. Date requires a permit fo construct,alter,rmPrave,demn[isfi,
... ...... .......�.,_._..,.,.,. . ,.,�_ ' �, orrepairanvxtructure,Ariortoitsissuance,alsoreyuires
� � ' tbe applicunt Jnr such permit to file a siqned xtatement
�hua h��:t�cens�d yunu�nc a,al e pro�,.�1o2s J eh�Con-
� 6ractor's(.dmnse Law(Cbapter 9J(cnmixencing u�itb Sec-
. . , lion 700(1/r f Dinision 3 of tbe Bu,siness and Professions
CodeJ nr that be is exempz eberefrnm andlbe bwix for the�
alleged e,xemption.Any v3nlntion of Section 703(S by'
Required uni�upplicuna fnra pern.it suhjects tbe applicant to u cie�fl
A rovals Dofe Recelved
PP Yes No or Approved . Qenultp of not mure tbaa fine hundred dnllars(SSOOj.J:
. L. I,as owner of the property,or my employees with
Water Certifimte � � .-- wages as thelr sole mmpensotion,will do the work,ond
ihe structure is not mrended or of4ered for sqle(Sec.7044)
Health Deparlment . - - 6�+..ciness and Pmfessintts Code:Tbe Contructnr's l,icense
Law does not app11'to an ou�ncr of prnperty who builds
Fire Deportment . . .. ,. .._....... or imprnaes tbereon.and u�hn dnes such u�ork himse[f or
t!rnugl bu o n employees, prnaiderl that such in:-
Grading , prnuements are nnt intended nr nfJered jor.��¢le. If,
bou�ever,eGe b:ailding or imprnr�emen[is sold u�it6in nne
Geoloqical vear oj cnmpdetion, the nu�ner-hudlder url!bane tb¢
burden oJ proving tl�ut he did nat huild or inepm��e jor
Pedestrion Protecrion . . tl e j:orpose nf.culeJ.
(Fence)(Conopy) - � CI I,as owner of ihe property,om ezdusively mnlrac-
� .. . . . .. iing with licensed contrcUors b construcl the projec�(Sec.
Speciol Inspection 7044)Busine.ax and Pro(esslnns Cnde: The Contractor's
(Canc.)(Masonryl(Weldingl � - - . License I.r�u�doesnat opply to¢n owxar ofQmpert1'u�bo
builds or dmproves tberenn,awJ u�ho contrae:ts fnr such
Lot Drolnage � � - �- � ^ � � � � �- ...projects witi a rontructor(.sJ licenseJ pursuant tn the .
Contraclor's License I.ou+f.�
Garkinq � . . .. •.. . ,_.. ..
7 I am exempl�under Sec. ,B.&P.C.for�his
repson
� � ... . , ,. Doie Owner
Approvals DaTe Inspecfor's Signoture �
INSPECTOR'S NOTES
Lomtion--� . . .. �. � - ..
(Se�back 8 Yards)
Foundations �� ' ' �` �� '" �
Slab _ .. .:.... . ...._.._.. ....
,.:; ......_._ . .
Frome � . . ,. _ �. .,._ ....._ ..
Energy Insularion � � � � �- ��� � � ��-
�Oth/D�ywP��- ,. . . .. . _ . . _ . . _ -.
�nterior ' '�
Lath-.Exterior - � �
House Number— � �- " � ' ' - " - '� � �-•-��. �.---,
Correct 8 Posted
Final-� � � �
Enter on Front -