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HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (112) . ' ' WORKERS'COMPENSATION DECLARATION j'� I here6y affirm ihat I hove a certificote of consen�to sel4 APPLICATION �OR BUILDING PERMIT I I insure,or a cerr�ficate of Workers'Compensation Insuronce, �� o�a certif�ed copy thereof(Sec.3800,Lob. . �''' COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No1��a^Y BUILDING � Certified copy+s hereby Pumished. FOR APPLICANT 70 FILL�IN ADDRESS p�f��a� � Q �� � Certified copy is filed with rha county building inspeo- BUILDING� /��h��t � tion deporimeni. ADDRE55 V��y i� r v.v� (,¢f�(,fi� r �o�e. '�-�-a-�P Applimnt JC' C�TV f ZIP tOCAL�iY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BL�GS. � NEARES7 COMPENSATION INSURANCE SIZE OF LOT �9 K �-�Z- NOw ON LOT CROSS ST. (This section need not be completed if the permit is far one ASSESSOR hundred dollars($100)or less.) TRACT eLOCK LOT NO. Mp,p gpq( PAGE PARCEI � TF�� USF ZONE �+P I certi4y thot in ihe performonce of�he work for which this OWNER ,� NO. — 15 ,vo. 1.�`b �-3�- permil is issued,I sholl not employ any person in any manner qDORE55 Cj,� V'e -.5��1'N -/�1CS'L G� SPECIAL �• so as to become subjecr fo the Workers'Compensation laws. CONDITIONS � ! i U Da�e Applicont CiTY ZIP .. � NOTICE TO APPLICANT: If, after making }his Cerfi{icote af ARCHITECT OR TE�. py DISTRICT GROUP NPE FIRE PROCESSE�BY C� Ezemptian, you should become subjecf lo Ihe Workers' ENG�NEER � NO. �^OGI CONST. ZONE F— Compensation provisians o4 ihe Labor Code,you must forth- �^ � 1/� y � ith comply w th such provisions or Ihis permit shall be AOORE55 V� '.TEL{ 1 V � a C1BemeCJ fevokecl. $TATISTICAL CL4SSIFIC ION APT. CONDO. (n CONTRACTOR NO. Z LICENSED CONTRACTORS DECIARATION �i�, CLA55 NO. DWELL UNITS � I hereby affirm iha�I am licensed under provisions of Chapter 9 A�DRESi NO. (commencing with Seclion 7000)of�ivision 3 04 ihe 8usiness and ��� SEWER MAP Professions Code,ond my license is in full force and effect. CITV CIA55 BK � VALIDATION �" 54.FT NO.OF NO.OF CHECK � �a LicenseNumber Lic.Closs_ SIZE/�- �- S70RIE5 FAMILIES ONE ) (�+p ,1 VALUATION ontractor Dale DESCRIPTION OF WORK �l� ^.�L� /V A�D O s�'i ('�(\� � ���(���� � VV I am exempt under Sec. � ALTER 8.8P.C.for this reason REPAIR s Dafe: USE OF C>' t-_ � DEMOL ❑ EXISTING BIDG. s� � + a��g�8 APPLICANT TEL. p. Signolure PRINT NO.� .y�-�a � F�NA� ; n p p�; OWNER-BUILDER DECLARA710N DA7E 3 �' �+'u c. I hereby affirm ihat I am exempt from ihe ContraUor's License � p Low for the following reason(Section 7031.5,Business and AooRE55 p�ryp� ��,��..�8 Professions Code): ENT � gY � ❑ BUILDING �, os owner of�he propeNy, or my empioyees with ADDRE55 wages as their sole compensation,will do the work and � the structure is not intended or offered fo�sale(Section IOCA�I7Y 704a,8usiness and Professions Code). MOViNG ie�. � I,as owner of ihe properry,am exclusively contracring CONTRACTOR NO. � with licensed tontraciors to constrocr the piojett(Sec- qDDRE55 1.���'�� tion 7D44,Business and Professions Code). ,�(•�� CONSTRUCTION LENDING AGENCY SET�BACK YARD HWV T�TApROP.ALCNEF WIDTFi �/ I hereby affirm ihot ihere is a[onsiruciion lending ogen�y for FROM ihe performance of the work for whith ihis permit is issued P.l. (Sec.3097,Civ.C.). SiDE P.L. Lender's Name LDMA Ref.k Lender's Address P.G Pea 8 Permn Pee ' I certify ihaf I hove read this applicarion and state�ha��he issuance Fee LDMA P/C N _ obove informofion is carrect I agree to tomply wi�h all County ��,res�igorion Fee ordinances and State lows reloting to 6uilding consfrucfion, Tota!Fee IDMA Perm.fl ond hereby authorize representatives of this County�o enter �pon 1ha abo�e-mentioned property for inspetlion purposes. . 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