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HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (93) WORKERS'COMPENSATION DECLARATION ,J� I hereby affirm thot I hove o cer�ificot�e of consen�io self APPLICATIQN FOR BUILDI�NG PEt�MIT ��..; ��sure,or a<erfificate of Workers'Com ensation Insurance, or o tertified copy thereof(Sec 3800,Lab.C.) - ('�p COUNTY OF LOS ANGELES BUILDING AND SAFETY Poli.cyNo.KE���Company �AIRMDN i BUILOING ��A Cer;iffed copy rs hereby fornished. FOR APPUCANT TO FILL IN ADDRE55 �l j� S ,(]' 1"�bN� �� � Certified copy is filed with the munty building inspec- eUILDWG �� ,r-J,� � �/�N p�,� tiondeportment. q� ADDRESS i' J �V7 �fl £Y'S� Date ����'J Appli[ont_ `�V(xi`�;i'��i+�,�1(�'� , CITV - ���� �Y�� ZIP LOCAIITY ��/V/ CERTIfICATE OF EXEMPTION FROM RKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE 51ZE OF LOT NOW ON LOT CRO55 ST. (This sectian need nof be compleled if the permii is for one ASSESSOR hundred dollors($100)or less.) TRACT BLOCK LO7 NO. N�P,p BpOK PAGE PARCEL TE�' USE ZONE MA7 I certify that�in the performance of the work for which ihis �`NNER � � �' U NO.��`t"'��� r�7' NO. f� � � permit is iuued,I shall not employ any person in any mannar qDORE55 �o� V .Y �6e,,� � " SPECIAI �� � 0. so as fa 6ecome su6ject to the Workers'Compensation Lows. CONDi710N5 �J o CITY 1 �l � 21P t��"� V Date Applicant ARCMITECT� TEI. , � NOTICE TO APPLICANT: If, affer making this Certifiwfe of DISTRICi GROUP NPE F�RE PROCES.SED BY Exempfion, you should become subjact fo ihe Wo�kers' ENGINEER NO. �,p� CONST,./� ZONE U Compenwtion provisions of the Labor Cade,you must forth- ADDRE55 "� �� ��'t' �� wi�h comply with such provisions or this permit sholl be OW.. deemed revoked. ' i � 1 tn� �G NO!C tF,j�G,�.�I STATIST�CAL CtA551FICAT10N APT. CONDO, cn CONTRACTOR h1 1-i`i lG`8 � IICENSED CONTRACTORS DECLARATION ���. ' CLA55 NO. DWELL.UNITS —. I hereby offirm that I am licensed under provisions of Chapter 9 aDORE55��0�7 �BY�� S� �� NO. �4'�'rD''�� (commancing with Sec�ion 7000)of Division 3 of tha Business and ��� SEWER MAP Prafessions Code,and my license is in full force and effect. Citt hca�b-rc� CLA55 �- BK � VALIDATIOk �F � SQ.FT. NO.OF NO.OF CHECK License N❑ er�Lia Clpss SIZE STORIES FAMIUES ONE I� yt VALUATION CoMracior � � y Date v � O DESCRIPTION OF WORK N� ❑ �}'� :s+ s �po__- =_4 4 4 3 A ❑I am exempt u er Sec T NdpfNT f� ��M�M117 A�DR a � +�q a � a i 3 B.&P.G.for this reason �l r��M1-+ �`13«-.. REPAIR � s � a ��2�f L Dafe: EXIST�ING BLOG. �,a5� DEMDL ° � �J����;cSi APPLICANT . � TEL Signature PRIN71 -j��ni �.--iLi NO. gl 3�i�-�{ FINAL � .� `� �F,�L J'-�b 7 OWNER-BUILDER DECLARATION I DATE a I hereby affirm ihaf I om exemp�from the Controctor's License ADDRE55 �7 S ��% � ��'�'� bd�'. 'd 9 6'7�1 Law for the following reason (Section 7037.5, Business and FINA}� Professions Code): pze � � BY �\�. `�`"`�� 4 a : 4 a� � ❑ BUILDING I, as owner of�he property, or my employees wifh ADORE55 wages as their sole compensmion,will do the work and 1 ' '�?S',�� �he structure is not intended or offered for sale(Section �OCALITY 7044,Business and Professions Code). MOVING TEL. " � m 1 j,C O c=i � I,as owner of fhe property,om oxdusively contracting CONTRACTOR NO. with licensed contractars ro construct the projett(Sec- �II.� L`�� lion 704d,8usiness ond Professions Code). ADDRE55 CONSTRUC710N CENDING AGENCY SET�BAC� VARD HWv T�TAp�ETpA�NE WiDTFI I hereby affirm that�here is a construc�ion lending agency for FRONT ihetperformonce of 1he work for which fhis permit is issued a.L. (Sec.3097,Civ.C.). SIDE P.L. LencJer's P1ome � LDMA Ref.k � P.0 Fee$ Permit Fee ' � lender's Address oI certify that 1 have read ihis applica�ion and stafe ihof ihe �aava�ce fae i LDMA P�C# � above information is corract.I agree to comply with all Co�nty Investiga�lon Fee �� c ordinantas and State laws relating to boilding constroction, Toml Fee �i S LDMA Parm.# and haraby authorize represenfatives of this Caunty fo enter � opon Ihe above-mentioned property for inspeciion purposes. . r ����0 _���y� ,,,L iL� EI�� g SEE REVERSE FOR EXPMNATORY LANGUAGE "F SignoNre f Appliconl or Agent Dafe / �l / , __ ...__w_�w__.._...____._._._.._._._.._._m__.._.._.__._.�..�...___._.__�,� _.._. _ m__.___�..__._.._�_._.. , ,_._._ ,a. ;� , s� .. .�, ;�� _.____.__ _����_�_ _..�_.�_ _.......__u_..�.. _..w_..__.__�__ . .� _ . , . . _ . .. �se-e+'.-€�r . � • ., . �<„.,...r ' _'.'' 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