HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (113) WORKERS'COMPENSATIONbECLARATION � . -�U/��� ... .. /" . —.. . � '
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I her�by affirm thar I have a certifimle of consenf to self APPLIC�►�I�N F4 BUILDING-PERMIT`��
insure,or o certificate of Workers'Compensation Insurance,
or o certified copy thereof(Sec.3600,Lab.C.) ���`� - �
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COUNTY OF LOS ANGELES BUILDING AND SAFETY .
Policy No. Company . . � ...----.. . �. . - . . . .
� Certified copy is he�eby fomished. fOR APPLICANT TO FILL IN sui��wG 1 � .�
ADDRESS � ' -(�f / ,_,, � �/�
� Certified capy is iiled wlth the munty building inspeo- BUILDING / 't
tion depdrimenf. ADDRE55 �!5J �O��V' : "' _ 1 y� 1
Da�e Applicanf CITY 1��/,ti�vr �� ZIP LOCALITY
� CERTIFICATEOFEXEMPTIONFR6MVJORKERS' NO._OFBLDGS. NEAREST /� -�. �����������---���� ����� -
COMPENSATION INSURANCE 9ZE OF LOT NOW ON LOT CRO55 5T. l`,7�!Kl� {� �
(TFiis section need not be completed if the permit is for one ASSESSOR
hundred dallars($100)or less.) TRAC� BLOCK LOT NO. MqP BOOK PAGE PARCEL
.n � ,�J TEL / ^�i� USE 20NE '�P Il�—
OWNER � � (i� NO.W� NO. y
I cenify that in ihe performance of the work foi wh�ch rhis �'4' SP�iAi d
permif is issued,I shall noi emp�oy any p n in an manner ADDRE55 �R=�.� " � CONDITIONS �
so as 7a 6ecome subject to ihe Workers' mp�sa' n Lawa V
/�%c��`7C'... . iy�.�^�'— CITY ZIP. K
Date '�,�.,�Appliwnt Y� """ - �
NOTICE TO APPLICANT: If, after making hhis Certificate of ARCHITEC�OR TEL. DiSTRICT GROUP NPE FIRE .PROCESSE�BY
ENGINEER N�� CONST. ZONE V
Exemption, you should become subject ro the Workers' p � y�
Compensation provisions of the Labor Code,yo�must forth- AO�RE55 L� y
wi�h comply with such provisions or ihis permit shpll be ' ' ��� TEL G"'/ S7ATIS7ICAL CLASSIFICATION APT. C NDO. �
deemed revoked. � . CONTRACTOR - , "'�.7t '4L{IJO. �Y'�""�SS-1
LICENSE�CONTRACTORS DECLARATION �q � �i�_ J��7 r; aAss NO. z�DWEL.UNIiS
I hereby affirm thot I am licensed under provisions of Chapfer 9 ADDRE55 j � ��'. ���✓'T' ) NO.`7 J� 7 U� SEWER MAP
(commencing wRh Secfion,7000)of Division 3 of the Business and . -� LIC.
Professions Code,and my license Is in full for<e and effect Ciry �j�}:'„�C , �c:- i�CtiY'C.:.'}ClASS C� � .j BK PG VALIDATION
- .c� �- f ,{i 54.Fi. NO.OF NO.OF CHECK
� � � "�/� SIZE STORIES FAMILIES ONE
License Number ��""� ���1 Lic.Class�_ � �
VALUATION .
��y�-�\� '] OESCRIPTION 6F WORK � — L•I NEW
Con�raCtorr,�.�-�^�� "'1�Dafe m`� � App S ����'/(�,LjG'� , ��
�I am exempt under Sec G • `��'' � " K-' q��R � q
B.&P.C.for this reason - .REPAie ❑ a r1�S•U�
USE OF � f(��Z��Q�
Date: DEMOL
EXISTING BLDG.
Si nalure � � - - APPIICAMf TE�� p FINAL -
9 PRiNT)�J.' .�•^_ i'� NO. JL -?" .
OWNER-BUILDER DECLARATION _ DATE �
I hereby affirm thot I am exempf from ihe Contraclor's License �- . � �r—
Law for the following reason�(Secfion 7031.5, Business and A�ORE55 `i '"' '�13 FINAL�
Professions Code): ' P ESEN By
❑ swmiNc z�4 J.b A
I, as owner of ihe property, or my employees wiih ADDRESS
wages as their sole compensation,wil I do the work and o
the struct�re is not intended or offered for sale(Section LOCALITv ' #J a m m s�
7044,8usiness-and Professions Code). MOVING TEL.
� I,ps owner of fhe propeny,dm exclusively contracting CONTRACTOR NO. � % e�b. f J
wi�h licensed coniroclors to consiruct ihe projecf(Ser qpORE55 .a m�e,S z
tion 704d,Business and Professions Code). U'�S�'
�'CON5TRllCTION LEKIDING TiGENCY -� ���� � SeQBAC� �ARD HWY T�TAp OTP.LINEF M WIDTH
I he�eby affirm lhot fhere is o consfruction lending agency for iRON7 � � 1•r'���6
the performance of the work for which this permit is issued P.L.
(Sec.3097,Civ.C.). SIDE
� P.L.
Lender's Nome
pje_,�- � / LDMA Ref.N
P.C.Fee 5 v(y7 r Permit Fee !y. � ' .
- Lender's Address t
I certify that I have read this applimtion and stofe that the Issoance Fee ��' J� LDMA P/C N
� above informption is rorrect.I agree to comply with oll County in�estigar�on Fee z !,
ordinances and State laws,ralating to bu��ding consir�cfion, Toial Fee �..J�� `+ LDMA?erm.#
; and hereby thari presenlatives of ihis Counfy fo enter
; upo�the ve-m nti ed property for inspedion urp es. , , �
: . ._ .._. .._ ..... ._..... _ ,.. .
� X � �"1.�----- � � SEE REVERSE FOR EXPLANATORV IANGUAGE
ignafure of Applimnt or Agent Dote ' ' - � ��
�.,,.«..-�..�. �.,raw�w,----�-- .
PLANS TO APPLICANT INSPECTOR'S NOTES O44M1ER-BUILDER DL:CLARA"I70N
„ ,. _ ,,,_ , : ,,. I hereby affirm that I am exempt from ihe Contrattor's
To: Returned License Law for-iFe following redson. (Sec. 763L5�
� Approved Busrness anJ ProJessiotts Code:Any city ar county u;fiich
No. Dafe No. Dofe requires a�ermit to construct,ulter,imvrove,r6emolisb,
. . . ... . . .,. _. rep¢iruny structssre,prior to its Jasaance,ul.m requeres
� 1L�e appliront fnr such permft to f+'le a�igned statemettL
. . ,. . , [bat he rs licensed pwrsuant to tbe provisinns nf tbr.Cort-
trnc�dor's I,icenre I,aw(Cbapter 9)(cvmmencing wrth Sec-
.� tion 7000/nf Di:�ision 3 f tbe/3nsiness and Pr fesslnns
CndeJ or tbut bo u exempt tberefrom and tbe basis/nr tbe
,_ alleged exemptinn.Anv riolatton rf Seceron 703(J 1s'
Required Date Received . unY'applicant/ra permit subjects the applicant to u civil
Approvais nult_ o >t morc tban bundred dn!lars $500 J
Yes No or Approved .. . pc y f n. Jive ( J.:
- J I,os owner of Ihe praperty,or my employees with
Water Certifimte - - � �� � wages as their sole compensation,will do the work,and
the struciure is not intended or offered for sale(Sec.7044)
Health Deportment . - Business¢nd Prnfesn�ions CoJe:1'be Contrac[nr4 Licerzse
I,au�does not upp[y to an ou�ner of propertt'whn builds
Fire Depariment . or rmprnx•cs therenn,unJ uha does suc5 work himreljor
, thrnugti-�his nu�n empdqyecs,�prnvided�tfiat such im-
Grading � � ��flmoemettts are nae intended or nffered for sale. Ij,
hou•eneq the bnifdrng or improvement is.rold u�itbin one
Geologicol - year q(rompletion, tbe numer-breilder will ba:•e tbe
burdan n�pmning tbat be did nnt bvild ar imprnve fnr
Pedestrion Prote<tion � t!e purpose qf saleJ.
(fence)(Canopy) �❑ �,as owner of the proper�y,om exdusively coNroo
�ing with licensed coniroctors�ro consir,Jct the pro�eU(Sec.
Speciol Inspection 7044)13usrrees.��ursd Professiuns'Cnde: The Cnntrartnr's
(Conc.)(Masonry)(Welding� �� --� ,- License Luu•does not a(�p[y tn an owner oJproperly u�bo
buflds nr imprnres dherenn,and wbo rontr¢ctr for such
Lot Drainage � � � . projerts wit!u coniroc6or/sJ licerased pursuant en tbe
Cnntructor's License LaruJ.
Parking - � �. I am exempt under Sec. ,B.&P.C.for ihi's
eason
- .. . . - , , Date . . . . - Owner ..
Approvals Date Inspecfor's Signo}�re
� INSPECTOR'S NOTES
lomtlon— .•.... -.. .
(Setbock 8 Vords)
Foundations
Slab � ... . .,, . :. . , ... .. .
Frame ,.. .. . . . . ,. .. . . � . .,_
Energy Insulotion . . � �
Lath/Drywall.. . , .. : ..: ............. , .. . _......, . . .
I Neri or
Lmh�--Ezrerior
House Number � � - � � - �
Correct 8 Posted
Final-- " , ' �
Enter on Fronr