HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (95) WORKERS'COMPENSATION DECLARATION � � �
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I hereby affirm that I hove a certificare of consent ro seff AP�PLICATI�d��l����1�0�� ��� I�I�IG����RM��T-
insure,or a certificate of Workers'Compensafion Insuronce,
or a f�rtlfied2opy thereof(Sec.3800,�a6.C.) COUNTY OP LOS ANGELES BUILDING�AND SAFETY- �
PolicyNo. Company
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILOING ��
ADDRE55
� Certified copy is filed with ihe counfy boilding inspec- BUILDING . { ^
tion department. ADDRESS „��a,�, �OCALITY
NEAREST
Date Applimnl CITY � ZIP CROSS Si. '.�
CERTIFICA7E OF EXEMPTION FROM WORKERS' NO.oF aiDGS. .455e550R
COMPENSATION INSURANCE � SIZE OF LOT NOW ON l0T MAP 800K PAGE PARCEL
[This section need not be compleled if the permit is for one USE ZONE M/+P �.
hundred dollors{^y100)or less.) TRACT BLOCK LO7 NO. NO.
I certify ihaf in fhe performante of ihe work for which this OWNER � 1� " NO. S � ��` CONDRIONS �
permit is iss�ed,�shall noi employ any person in any manner DIS7RIC7 GROUP TYPE FIRE PROCESSED BV 4�
so os to beGome 5ubject to ihe Workers'C mpensation Laws. ADDRE55 �r E � CON ZONE �
4 ) � �j N �. � �
7 ��` �' Cliv[,_'e1 �� ZIF �� (1 �o �
Date ��Applicant � STATISTICALCLASSIFiCATION APT. CON�O. �
NOTICE TO APPLICANT: If, afier making this Cer� " e of ARCHITECT OR TEL. ['�S�
Exemption, you should 6ecome su6ject ta ihe Workers' ENGINEER NO. CLASS NO.�DWELL.UNITS �
Compensation provisions of ihe Labor Code,you must forth- qDDRE55 SEWER MAP �
with comply with such provisions or ihis permit shall be �
deemed revoked. � TE�'� VALIDATION
CONTRACTOR fI/?k U�" NO:Z13"�3�glZ'I eK. PG,
LICENSED CONTRACiORS DEClARA710N' ���.
I hereby affirm that I am licensed under provisions of Chapter 9 nDORe55 No. VpLUAT10N
(commencing with Section 700D)of Division 3 of fhe Business and LIC. ,��
Professions Code,ond my license is in full force and effeci. CITY CLA55 S ►
� SQ.FT. NO.OF NO.OF CHECK
License Nombei Lic.Clqas SIZE STORIES FAMIlIES ONE
DESCRIPTION Of WORK � NEW � s
Contracfor �ate � �-
❑I am exempt under Sec. �1�^ ��l 1� � AOD � ��l!
� ALTEe � FINA ��
B.&P.C.for ihis reason � OAT
'�1 REPAIR a �-.�L L 1 A
Dafe: E%ST�ING BLDG. �����C+', C (, DEMOI � FY'�'t � .
APPLICANT TEL B �� � � e�3
Signaiure .
OWNER-BUILDER DECLARATION PRINT _ NO. ►�� � i J�J��
I hereby affirm ihat I om exempt from the Coniractor's License -.z�� ,y 7 '
Law for the following reason($ettion 7031.5, Business and ADDRE55 �'7 L , _
P�e55ion5 Code): PRE E T c � �'��~''J��
i, as owner ot ihe r o� p y gUILDING I 1,6 6"8 6
proper y, my em lo ees with ADDRESS
wages as their sole compensation,will do the work and `o��ITY
the structure is not intended or offered for sale(Section •``-'3 4 2 2 A
7044,Business dnd Professions Code). MOVING TEL.
� I,as owner of fhe property,am exclusively contracting C NTRACTOR NO. �r e e a a�
wifh licensed contrqcrors to constroci ihe projecf(Ser ADDRESS
tion 7044,Business ond Professions Code). - � o °�(�j G
REQUIRED TOTAL SET6AIX FROM EXI57.
CONSTRUCTION LENDING AGENCY $ET BACK �AR� HWv PROP.LINE WioTH
I hereby affirm that there is a construction lending agency for FROnIi ► � ` `J lA rJ(i c:
the per4armance of the work for which�his permit is issued P.L.
($eC.3097,Civ.C.). SIDE � �,U c5'��J
- v.�.
Lender's Nome f��. (�@
� P.C.Fee$ �.:/ Permit Fee V�Q
Lender's Address n
I certify that I have read this opplication and state Ihat the issu ce Fee �`Y �
c above informafion is correct.I agree to comply with all County Investigation Fee
a ordinances and S1ate lows relating to huilding consiru[fion, Totol Fee
5 and hereby authorize representatives of this County lo enter
� upon fhe a ov -menfi ne property for inspecfion purposes.
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o \ �j?�-� �/��"a� SEE REVERSE FOR EXPLANATORY LANGUAGE
� Signature of pplicanr oP t, Dare �s
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._ ___" t -.. �_._ .. . �I,as.ov�nsr c£9he�.pr2l�ertY,.or my erma:oyees wi!h
`.Nater Certr a� � � ' . � _=_ - ,ne-as.c 9�c' so compe�ep-c i'!qe iFe ovork,ond
��.�e s uctu s s o ir+•cnded o c-�e�,c'for sale(Sec 7044;
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