HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (102) WORKERS'COMPENSATION DECLARATION �r� �U�1_.+ S`�� r,q
�nsurebor"afcerlifcateofWokes'rCompensatonensuranelf APPLICATION FO� BUILDING PERMIT Lt
or a certified copy ihereof(Sea 3800,Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑olicyNo. Company - C"
Cerrified copy is hereby furnished. POR APPLICANT TO FILC IN noosEss � J 5 � �� �
� Certified copy is filed with Ihe county building inspec- BUILDING (� {��n
tiondepartmenf. AD�RE55 � ���,J �}f'CR�. LOCA!I7Y
� NEAREST " �n� 1�
Date Applicant CITY �� .ZIP CROSSSf. TTI��
CERTIFICA7E OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SrzE OF iOr NOW ON LOT MAP BOOK PAGE PARCEI
(This section need not be completed if the permit is for one USE ZONE MAP 1 ,r
hundred dollars($100)or less.) �RACT BLOCK LOT NO. /} NO.
�,�-"� Cr� SPECIAL ;Y
I tertify that in ihe performance of the work for which ihis OWNER� � O.�.TI�' CONDI710N5 .�1.
ermit is issued,I shall not em lo an erson' n manner t'� [` 1ti-J�..�...-...\� -, _J{� DISTRICT GROUP TVPE FIRE PROCESSED BV '�
P I P Y Y Y /� CON T. T ZONE �
so as to become sub'ect b the Worker Com ns tion Laws. ADDRESS 7 .�J f�e'KJ�+ L-4!U 6
] �• �`"� Pr
Date •� Applican} AIRCHITECT OR Z P TEL. STATISTICAL CLASSIFICATION APT. C NDO. �
NOTICE T APPLICANT: If, ofter making this Certificate of ENGINEER NO. CLASSNO. � DWEIL.UNITS �
Exemption, you should become subject to ihe Workers' �
Compensation provisions of fhe Labor Code,you must forth- qDDRE55 SEWER MAP
with mmply with such provisions or this permil shali be —�� -ry� �
deemed revoked. CONTRACTOR {{.�.:��G SI O BK. PG, VALIDATION
LICENSED�ONTRACTORS OECLARATION , . , uC. , �
I here6y affirm that I am(icensed under provisions of Chapter 9 ADDRE55 NO. YALUATION aO '2 _�
(mmmencing with Section 700D)of Division 3 of ihe Business and .q���, P �^^ ���, � oLL1
Professions Code,and my license is in full force and effect. CITY ' ��`�{�vJ���:/� 1...�'F= CLASS '• $
C� SQ.FT. NO.OF NO.OF CHEIX ' �Ja
LicenSe Number ��� L�� Lic.Clpss� SIZE STORIES � FAMILIES ONE
{t���.�}�,� r�r���/�� s ^� �F �'1 ' NEW �
Contra[for C'.lS�l.1 C4!'LI l� Ji[✓`�6ate 1� rJ^� �80 DESCRIPTION OF WORK �� fJ�j
.�..y � ADD �
�I om exempt under Sec. � �'L-�-
c A�TER � FINAL
B.BP.C.for this reason J�� g � DATE `�,/� � �a����'�
REPAIR
�}e: USE OF FINAL �
EXISTING BLDG. BY
Signafure APPLICAM TEL.
OWNER-BUILDER DECLARATION PRiNi) �+P�-i.il�Sfb O. � _
I hereby affirm ihat I am exempt from the Contrador's License ir°! 51)�u.,O e,., h �.,p��� /^. ,,, ,
Low for}he following reason(Setlion 7031.5,Business and ADDRESS {=.T� �\C�-f�117���R� l..t..�_
Professions Code): PRESENT
❑ �BUILOING
I, as owner of the properfy, or my employees with ADDRE55
wages as iheir sole compensation,will do the work and
the structure is not intended or offered for sale(Section �oCnLiiv
704a,Business and Professions Code. nnOViNG 7E�.
� I,as owner of the property,am exdusively contracting CONiRACiOR NO. %J��������
with licensed contractors fo construct the project(Ser qppRE55 i; a m s e��
tion 70C4,6usiness and Professions Code).
REQUIRED TOTAI SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH ; a��S 7 v
I hereby affirm that fhere is a construction lending agency for FRONT
the performance of the work for which ihis permit is issued P.�. a e, e�;C.']��
(Se[.3097,Civ.C.). SIDE
- P� f 1.G 1-�b
m Lender's Name
� P.C.Fee$ ��� Permi�Fee � -,y' �
Lender's Address
� I certify that I have read this application and state that the issu ce Fee '�'s�
¢ above information is wrrect.�I agree to tomply with all County invesi�ga�ion Fee an �
g ordinances and State lows relating to building construction, 7orol Fee
and hereby authorize representatives of ihis Counry ro enter
� upon the 6ove- � ned property for inspectio�n�p��rposes.
n �jyZ���:4`� J(�71 a,� SEE REVERSE FOR E7CPLANATORV LANGUAGE
_t_
�S�gnat�re of Applimnt ar Ageni _pDore - �s
,..m�--- m,...�..��a�..�.+.rws.�rn�,s-...:ec,�.+.m�w,�,�..-�..-..._...T-«9- _'
.. - QlAi3STt-¢,�,.�1iS18N7 . . . ��_. _ 6NSF�s&'d�R'S�IS)5'ES �� �,�x:1 � . t i5f��b a�^Ta�h, ,
� r I here6_ o§r, tfm�-I rm ex mpf'.am 1 e C�.1 cc �
Fefe�� � . Rei�aess�ai .- - - .- .�-•-.._'_�__�_..� . Lice.� c v or n �fci o i cy neso� IS e�704 .5J
;�--- _,} ARSi4vRd - i?k.._ ..aue..cr... . ,...0 f-.-��r,-ye c�v.�.,✓ei.&:d�
I pla.�rt � G:.•R. �� "�co �cs^m � u h- ,r �i c r , r - �:�;r.clisl,
�T���� — ^ .' -E . 1 Y . SP�2'C- S.P¢a�YYCS
( I ,.Y xj j tx m t.�7 ern x e� f u- gas d tut�r:c f
L.�.. �......r.._ � -- �.. . '�e .. PF , e I s . ' __r �-� s s.J d�:c Co:.-
__}.._�.��
�
I , . :.,-, ....c..r,.r..,.,�,��:.e},.er5i�-:..,�r,°cs�.:z.,«�9r-p.Fer'
' i()�i�,I!1�LL4'::.YC.':i%5�,5�t;��:`hl?SS[i]?329'f1fC�SSin:iS
-- i l;cd:j<erpF,eFna:;szai;>,��t��P�r,.;.:sz�aradt.herarfsjn.rt.'�e
.i I - _...�..-,.�..._.- ,._.1.� _' — .
�";;,;cd zxes:�E<-'�r:.dr.� -.,,ol;._t�c'.:'r�j Sert?o;,iO3.'.5 b_�
_:'.�..._, R^�artoe� . ..
:?,^•[�r�v:�l� . �--��� 8'aTmR�astiveel +•uW:.�c:�s;fc:^:.,i.^;^:r.a;s:oFi�ects.rus�i`.+%i:r.a�zP;nacle�%:
an
' � y��. I , or Rppeovmd -----_._.__ ,.,.,.,, ,
,— ._T...A-,._..___.a__ _=_i .da . - � . _. _ �..,_n>.)�cf fet:r::;,-s ti;an;�:ve�::ar.raG elcP%�;a;:SQQ:.j:
-_._.._.. . . ..___ __ �. - � oS-� o��� a n(ope �.o . y em?loyees wtlh
NIeS��Cer'"tcte —I , � - . --'�-`— v S s cs t�e r s r myen ot cn,w � �ihe work,cnd
._��_._._.J�_�___� ,.... . _ i'n ��_�.ura u»c. �.,,e��?Edo c.ePc, ..,sae(Sac 704d�
iieai!h Deparimen��—� . , , —''--'-'- . N.•i.c,'�::::s cx�?F'rr;,rassir;,os Cr.r>c:",".�c�axt;.:crnr's Licensn
- . r,rz�•�,d;es r_or,h,s�:;,;o. zre:ay'of prn�r:er'sy:05o b::ii,;s
� �c r�� � — . _o"ri»,a�:<>s^:�alerres,r.-.drnfin:f:;e.e.-•r:%+cear�.i:�i:�:anl�cr
Fir�6¢� rtn-.•;;
�"'��_� � i.�l )1.�h i" J2(., � h.y f p7- S.ti'i :
Grcdir,c� I — j�r.' . s are�e z .� p-� ' j; r�f,r �a .`
��—_.._-_..__ .�.�. � .. . ,5a. t�ie cn
n s � ts 1 n
i G�olcS;ccl I _ . � . . �. . . . . �� .--- r 1 _o e o r �i � G�. �
; . ' � .. z-t...,:.>.n,f �. ,,.�. :.,..; �.�'...,,�. .,c.�.r.;,�.c,F�,�
�Pecastrian Pro}z:tionu.--i � .. _� � 'isc yu:};a:c:f sa.'eJ. - ,-. . . . . :.,: .
�c:�ca`(Cc�c I _.I'—"_ � ���;
( i PYi ' Iras.^. . ro :Fcr a ,^o c � s . ,ronirc.-
--�' I --� � PLiy�:ith i cs �cd c_ -cc o� const uc tne pro;eC;;ec
iSc�cici Inspaciion_._—_ � . � � I . 70A<i�a:::xn.vs e,:i:?rc}"_+:;3a�.6.-.s�:;ca'>� :�'h,•C:,n.•:,-uceo;1:
�Cci-�c.)(N�asonryl4Vdel�ir,gJi i I . > . . . = F:c.F=ei,c•�•E^.cs-r,±c3;�tytoc.�a,c:rare,i��r<:;:r;:%whn
� 'I huil.ls�ar'r,::i':':�res iL<ran;x,c�r.:;:Li:i.=uat6ucis;�:n�sucd+
�Lot Drainaae i .� � �.-...—. . . _ prnj;;ds - cr,.::x;cr„�r(sl firo:;-.. . . .;:t�
J_ ..r,.,e...r.rr�:'.�I,ie..rt...'i..v..., r.r >��_£?,r
Parki�----i . , .
� _�_� � . . '— ame �r� w�-�-�'---_- --6.C.?.0 fo�,-s
i
-- t- .:cso-
f - -- Catc_'_ Gvrn
��` 1 . . . _' ,_
I �� 5b��.�cva<s,�.T� I �ci� I ins�c�:lwr's Si�na4uro ^._,. �_ _. . ....,. -
����_�.—.,-----.._.__... �:."
:locat on �� _ . ....e,,..�.._.�. _..�. . _.-..... .....T.._...,w,,..,..
i(S6�J6CIC:'-��CPOS) I . .
�FOUl1G�:J}iG115w � I ' � . L . . . . _—
5--..,�.____ .___.__ _!_-- I
.S'�Q�J I ___
��__'_ ,� . _�. __--__—__—._—_—___— '
�_��.Frome �
� i --_ . ... . .... .�.. ....__ _ .� ....,:..-
�energy Insolcticn } '
�,,_, I
�LcPhIGYyWOlI--��_--_� , -- _ _—___ ___�_
I te ior
�
�a�ExPerior �'-- ._--'—_— _ �— —_— � ..
��.�.._.._...�—t—_ . . ..
�H�o�e Nu.r.b��.--_L _— _._—.--___ _--_—__�-. _— .. .
�Co_r:ect E Po?5od � .
'i Fin�l-. �'_ I �� .__ �..�. . __r.�._..._ ,
EnPnr on'ronS � . .
__-_—_. ... . .._.. ... -
..,.....�.-
I '_-- t , ---------'�-- _ .. __�__�.___'..._...__.�-�... —_ .
!