HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (111) WORKERS'COMPENSATION DECIARATiON � �� ������ \�� '" ��� .��....» . ._.W.. . ..... ,� . . , - -�
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I hereby aff rm Iha� I have q certificote of,consenl to self APPLIC�710��N��FO�R��BU�IL[�11V��PERMI`T�
insure,or a ce�Lficafe of Workers'Compenscilion Insurance,
or o certified mpy thereof�(Sec.380b,Lab.C.) �� � " � ' " ' � "� �� " -'" ' . . _.
PolicyNo.�Z��s Company_1����ryv.:�i.1-NS�o, COUNTY OF LOS ANGELES BUILDING AND SAFETY -
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� Certif�ed copy�s hereby fumished. FOR APPLICANT TO PILL IN gu��o�Nc� L� �Q �
� . . . ... A�DRE55 I fJJ ��C.r.�,yy�,�.� ✓dW .
Certified copy is-filed with the couniy building inspeo- eUiLORJG�., a, s. ,e�e�, S
tion deparimeni. ADDRE55 . -J {gf�F7� tir� �.� .L-��
� + _ . . . . ��-'^ n x� . . . _ _ _
' Dote 1'�7�� Applicar�t.'� CI?V y�!�.�j�^� �s` ZIP LOCALITY
� CERTIFICATE OF"EXEMPTION FROM`�WORKERS' �' NO.OF B��GS. NEAREST ..
- �� COMPENSATION INSURANCE � SIZE OF lOT NOW ON LO7 CROSS ST.
(This section need not be compleled�if fhe permif is for one TRAC7 BLOCK lOT NO. �SESSOR
hundred dollars($1002 or Ie55.) , I( MAP BOOK PAGE PARCEL
OWNER d S ti/ �T ' Nd��iS'!-����' USE ZONE �+P
I certify ihat-�i the performance o'f`the work for which�this - ' NO. j(^ �-,'r� }
permil is issued,I shall not employ any person in any manner ��...� SPECIAL� �-� � - - fl.
so as to become subjecf to the Workers'Compensotion Laws. ADDRE55�Z. 3 ti�� ��- - CONDITION$ 32�`2�� �
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Date � . .APplicam - CITY l�hY�:,.wcl�t 6rj,�:l0 ziP `�?,k9% . .. . �
NOTICE�TO APPLICANT: ff, after�moking this Certificate of !RctiliECT OR TEL 'Ih'� ;1� O
ENGINEER IN ``�`{ �"""(`, ryp. . DISTRICT GROUP TYPE fIRE PROCESSED BY
Exemption, you should become subject to the Workers' /� / CONST. ZONE W
Compensation provisions of ihe Lobor Code,you must for�h- qDDRE55 i'y'�"z. La1 � �2.� {'+�>l,-�. �',1.\;'[` �,, (� ��L� � d
wifh comply with such provisions or this permit sholl be � . .- .,. 'A
/' TEL:73 STATISTICAL CLASSIFICATION APT. CONDO. �
deemed revoked: . . COMRACTOR �(,� C-�x-F S�. NO. �S" �)
LICENSED CONTRACTORS DECLARATION � �i�,. CLA55 NO. DWELI.UNITS
I he�eby affirm�hai I om licensed under provisions of Chaprer 9 A�DRESS ,}-y�6Ti•/ �� NO. %�p Lj
(commencing with Section 7000)of Division 3 of ihe Business and t� SEWER MAP
Protessions Code,and my license�is in full force apd effecf. CIT �wL.c . CLASS BK � VALIDATION
� ' SQ.Fi. NO.OF NO.OF CNEIX f ^
(/�cense Num6er-���7d9 Li[.Class � 512E STORIES � FAMILIES ONE VALUATION � ��� � �
'-(.onfracfor�-P�`�''V 5T•. Date �-27"'.�� DESCNIPTION OF WORK .. . . N� s i4���� . ` .. °`�C', �
A�D
�I am exempt under Sea � �'��+�'�� � ❑ , _ p :j� t S' ,
- � . ALTER � _ �
B.&P.C.for ihis reason REPAIR ❑ s , , z"=;
_ . Date: � USE OF a "'� I.�..;;�.
EXISTING 6LOG. DEMOL
Signaf�re .. .. . . . . APPUCANT � � r. ,y`iEL. r - FINAL • .. : 7'—r�
OWNER-BUILDER DECLARATION PRINT) ,�� l= _ '�J,d NO.✓ ' +rJ DATE f �
I hereby affirm that I am exempt from the Controctoi s License - ,J
� Low for the following reason (Se"ction 7031.5, Business and ADDRESS - � �,rV��� �v� �r44�, !n'���1� FINA
Professions Code): � � aRE i � BY
❑ BUILDING . .. . .. _.. .. r .
i, as owner of ihe properiy, or my employees with ADDRE55
wages as their sole compensation,will do ihe work ond , �
the structure is no�intended or offered for sale(Section LOCaLiTY
7044,Business and Professions Code). MOVING ' � -�-- �TEL.
� I,as owner of the ro ert am ezclusivel con�ractin CONTRACTOR NO.
P P Y� Y 9 ='.�f,.,.�t�!%,
with licensed contractors fo conslruct the project(Seo- � qDDRE55
tion 7044,Business ond Professions Code). - +` �p
' CONSTRUCTION LENDING'AGENCY � � SEiaeACK� YARD HWY T�TAPRE�TPAOCEFROM yyIDTH � � � r � C��
I hereby affirm tha�ihere is a construction lending agency for FRONi ` � ; i Q,(�'v az�
the performance of the work far which fhis permit is issuad p.�. - - �
(Sec 3097,Civ.C.). SI�E Q ���%-w��� �
P.L.
Lender's Name
- ' ' P.C.Fee$ �/ �(3 Permit Fee ��j� {� ��''�Ref.q �
- Lender's Address ,
I ce�lify ihai I have read ihis application and state that the Issoance Fee .� tDMA G/C# �
� pbove informa7ion is correct.I agree to comply with all Counfy Investiga�ion fee
3 ordinances and State Iaws relating to building construction, iotal Fee �� IDMA Perm.N
and hereby authorize representotives of this Counfy to enter
� upon 1he above-meniioned properly for inspection purposes.
' P " � . . . . . .._. ... .__. .. . . . . .
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�/� /Z�-�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat�re of App icant or Agent Date - - - . .- - C
�
OW'NER-BL'II.DF.I2 DF,CLARA'170V ��'
PLANS TO APPLICANT INSPECTOR'S NOTES I hereby offirm fho�I am exempt�from the Contractor's
To: Returnad � License� Law for ihe fol�owing reason. (Sec. 7031.Sj
Approved Business nnJPrn(assdnns Code:Any cify or count.y u�1�scG
No. Dafe No. �aTe � � reyaires a nermit tn construct,alter.imf�rove,demnlish,
. . .,,,. , . ._..._..... ... OYYCri61Y6tt'�'SLY4cIllYC.QYlOY10tiSf5d'Y6#['f�(1150YPlfL1Yc'S
� tGc applicont for sucfi permit to/ile a srgneJ statemenl
. . . � .ebut he eslicensed pursuun(to thepror�isions f tHe Cnn-
�� tracMr's Licemse Law(CEru¢ter 9J(commencing u�itb.Sec-
. tinn 7000)nf Uia�isioR 3 of the Bmsiness�nd Projessions
. CndeJ or thut 1 e is uxempt tfierefrom nnd the 5asis jor tbe
. nllegud exemption.Axry violateon of Section 7031.5 by
Required un}'applicant for a permit subjeces t6c applic¢nt to a civil
A rovals Dote Received
PP Yes No or Approved . Qexaltl'of nnt mnre thas fix�e brendred dollrers(5500J./:
J I,as owner of the property,or my�employees wilh
Water Certifimfe � wages as iheir sole mmpensation,will do Ihe work,c nd
the srructure�is not intended,or offered for sale(Sec.7D44)
Heahh Depariment - � l3r.siness and Profassrons Crzdu:TGe Co,retractor5�Lecexse
f,aw does nnt upplro tn an owner of property u.•bo 5ssi/ds
FireDepartment --- -� --. ., nrimproa•eslherenn,andwbodoersuciworkhim.seljor
throug5 his oun_empinyoes,prqvided tbat such��ins-
Gradin �prozrerm-ants are not intended or nffered fnr sale Il,
g .
howeveq Ibe buildrng arimprovemert is sold witGin nxe
Geologiml � ye¢r qf completion, tbe nu•ner-builder u�il!bave tbe
. � , bu.rden of proeirre,q tbat be d!d�ot hurld or improre jnr
Pedestrian Protecrion tbe purpnae of saleJ. -. . � ,
(Fencel(Conopy) !.� 1,as owner of the property,om exclusively coMrao
ting wilF�licensed<onlroctors lo construd the'project(Sec.
Special Inspecribn � - . 7044`J3vsiness�and Prrfessibns Cnde: Tbe Condrdctor's
�Conc.)(Masonry)(Welding) - Lirereso l.aa-daes nnt�pply to an ouwer of properLy u�bn
bui[ds or rmproc•es thereon,-and wL�o rnalracts Jor such
Lot Drainage �-� � - - � . . prnjects witb a cpntractnr(sJ IicenseJ pursuant ro the
Cbn�ructor'.c I.ucnse Law/.
Parking ,_. I am exempt underSec. ,B.&P.C.for ihis
reason
� Date Owner
Approvals Dote �nspector's Signafure . �
- INSPECTOR'S NOTES
Lowtion— .: . - ... ^.
(Serback&Yards) .
Foundotions , J '�^ �. . ' .:.,.-.�r,.� ....:..:.. ...:..'... �
��` !�� � _.... .., ,. .. . _, , .
Fram ;��^ R - !� � . .. . ..... .. � , . .
y,
Energy Insulofion � j _ . _ �" .
�ath/Drywall - . . . . . ...... .. . . . "
Inlerior
Lath� Ezrerior ��
House Number- - _
Correct 8 Posted
Final--- " . .. . . . . —
Enrer on Fronf