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Home My WebLink About1155 SOUTH DIAMOND BAR BLVD (119) �WORKER$'COMPENSATION DECLARATION � � '�'- !ti� �f'a(��.� �� yereby affirm ihat I hoye o certificafe of consent to se�f - AP�LI�i4�(�N F�R BUILDING PERMIT � irisure,"ur,,:i cenificate of Workers'Compensation Insuronre, . . _ . _... ....-.._. ...___.�._...._. .. . ,. . .._,., �. : or a certified copy thereof(Sec.380i7,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolityNo. Company - - - . . . .. .. . . .. _ .. . � Certified copy is hereby 4u�nished. FOR APPLICANT TO FILL IN �-� BU1LD1NCi J c I,/�t t! A��RESS II S, y! rlfl�V :J -' �i V� - � Certified copy is{iled with rhe county building Inspec- - euil�iNG � - _ +�o�deparimenf. AD�RESS /% `J�J J�, %%IF�.{��/1.';?l�AI�1��%-�:: W�� +�;'� _ ....._._ __�._..___.:. �— .. . ... ._ __ Dote Applicont CITY ,A yI� '%� °%-{'�`. ZIP LOCALITY ... CERTIFlCATE OF�EXEMPTION FROM WORKERS' NO.OF B�DGS. � NEAREST l� /�{��\ COMPENSATION INSURANCE ' SIZE OF LOT NOW ON LOT CROSS ST. �%��Ly'��v�� (This section need not be completed if ihe permit is for one - � ASSESSOR ' .- . hundred doliars($100)or less.) TRACT 6LOCK LOT NO. M.4P BOOK � PAGE PARCEL OWNER-„�)}�'G P:Vr , NO.�� a.�?�..a USE ZONE h1AF 7'^ �r/ I certify t6at in the performance of ihe work for which this NO. � 7 y permit is issued,I shall no1 employ any pers� "n ony manner .t' C�� SPECIAL 4. so as to 6ecome subject to the Worker C p nsation Laws. %oDRE55 �1lL' - CONOITIONS U /�"-�„_� ' CItV ZIP . . . �. y� Date Applicont ARCHITECTOR �TEL ' � NOTICE TO APPLICANT: If, offer moking this Certificate of ENGwEER NO. DISTRICT GROUP iVPE , FIRE PROCESSED BY � Exemption, you should become subject to ihe Workers' �� N57. � ZONe �� w Compensa�ion provisions of ihe Labor Code,you must forth- with comply wilh such provisians or ihis permit shall be ADDRE55 TEL ,�s � deemetl revoked. CONTRACTOR��iF� "1.(�.SI�:�"S NO.�f �'�$�' STA7ISTICAL CLASSIFICATION APT. C� D0. Z LICENSED CONTRACTORS DECtARATION - '��_ ,/ -�- -- CLA55 NO. �Z'DWEu.UNiTS I hereby qffirm thot I am licensed under provisions af Chapter 9 AODRE55`�j�, ,� /-}j'S NO. "�7y��"�r SEWER MAP ' (commencing with Section 7000)of�ivision 3 of�he Business and ��. ��S, Professions Code,and my license is in full forca and effeci. c�Tv �� H '��y�j II'Ji�.f1' CLA55 BK P� VALIDATION (�. SQ.FT. NO.OF NO.OF CHKK ' liCenSe Number "'�� Lit.Ciass G�S SIZE ,�,',� STORIES FAMIUES ONE . . —�' � VALUATION „� �� Confractor �.��/�/Lpate �Q� � DESCRIP710N OF WORK ' !''�]� / NEW S . . - ADD � �'U�UIJ , �CJ�^ �I am exempt�nder Sec. ��- ' G� - �� aiiee [] B.&P.C.for this reason REPAiR S � Date: USE OF � �S-E'� EXISTING BLDG. ' � DEMOL ❑ J �/ Signaf Vre APPLICANT�; -y� TEL. �- r,} FINAL 7 `�'��V p PRINTI+=G�l��}"Ll I��E,/L' NO. S OWNER-BUILDER�ECLARATION _ .,. _ ....,,_�_...,_,,...� DAT� �C��'7 I hereby affirm ihat I pm exempl from the CoNractor's License e;� � %f,' � ry Law for ihe following reason(Section 7031.5,Business and /+DDRE55 �) .�-a��'�� FINAI/'` Professions Code): E BY C � ❑ BUILDING . , I, as owner o4 the property, or my employees with AD�RESS . __,._ ,_ ..___,_ __.._ _. wages as their sole compensation,will do ihe work and �� -� - �� , the structure is not intended or offered far sale(Section ��"��TY 7044,Business ond Professions Code). MOVING TFL. Y v[_� j h � I,as owner of the properfy,am ex<lusively coMracting C NTRACTOR NO. � with litensed con�rocloB to construct!he project($eo- pppRE55 �'e o�s e m'� tion 7044,Business ond Protessions Code). CONSTRUCTION LENDING AGENCV �� SET�BACR YARo HWY r�TApROPi1CNEFR WIDTH � 6 °�O� f� I hereby affirm thal there is o conslruction lending agency for FRONT ihe performonce of ihe work for which ihis permit is issued P.L ^ ^ ":J��(J� (Set.3097,Civ.C.). SIDE P.�. i i.L�7�-8 6 Lender's Name ' .� � q,. y�+ LDMA Ref.# - Lender's Address P.0 Fee S � > Pe�mit Fee - 'C.�i�• •'"J �� , I certify that I have read ihis applimtion ond state ihat the Issuance Fee l�'"�f LDMA PiC# above information is corcect.I agree to comply with oll County Inves�l tion Fee � ordinances a Srate iaws.relating fo building construciion, � - Total Pee - ��'�� LDMA Perm.# � and hereby uthori representatives of this County to enter � upon 1he ov�ent' ned proper}y for inspectio purpo s. . .. .. .. ' .." .`... ..`�'"..'�,....'."'.�"`"."' '."":. , :.• , - a SEE REVERSE FOR E%PLANATORY LANGUAGE � Signature of Applicant or Agent' � - . . . . .. v I � - PLANS TO APPLICANT � INSPECiOR'S NOTES 04�'I�L'R-6LILAER DECLAI,2ATION. I here6y affirm�hat I a empt from the Contractor's To: Returned License Law for the following reasan. (Sec. 703'S) Approved Dusiness und Prnfess{onr Code:Anp cety or cuunty which No. Dofe No. Dafe � requires u permit to��nnstrracf,alter,im/�rore,demolisb, or ropafr an ystnectare,prior to its issaa�nte,also reguares � , the applicant frir suc!permit tn/ele u si,Qxed.ctatement . tl ua he is[icensed pursuana ta the prox:istons rf ebe Con- trurtnr:��License Law/CGapter 9J(commencinq u�ith Snt- trox 7000J nf Dsvrsion 3 nf LGe Brasiness und Prn/nsaions _ CodeJ r r tbat be is exempt tl erefrom anJ the hasir(nr tbe alleged rrxemption.Any z•iolation of Sectian 703L5 6y Required � axy apf�lit��vt�r a permi!suhjects tbe upplicant tn a cir�il A rovals Date Received PP or Approved .pc�ulty o/�not more eban fice Gundred JoAara�($S00/.J+ Yes No _1 1,os owner of the proper�y,or my employees wirh Water Cerbficate wages as thelr sole compensation,will do the work,and the structure is noi iMended or offered for sale(Sec.70441 Health Department Dusrness and Professinns Cride:The Coxtractor's I.icense Lau�does not apply to an ou�ner nf prnperty whn builds Fire Department . nr tmhrnx�es tl erenn,unJ iubn doe.c suc5 mork hrmscljnr abrougb his own emhlnyaos, ¢rovidad tbdt sucb im- Grading pronemen[s ure nnt intended or offereJ f r sale. IL !owever,the buildin,e nr imprnve»aent is soJd u�itbiu one Geologiml, � year nf mmpletinn, 1he mm�er-5ailder u�ill bave tbe burden rf proving tbat fie did nnt fiuifd nr imprnue(ar Redesfrian Prolechon aJu¢urJose of sule/. (Fence)(Canopy) � I,asowneroftheproperty,-amexdusivelycontrac ling with licensed�onhactors to consirucr the pro�ect(Sec. Speciol Inspection 7044�Bu.��iness und Projessrnns Cnde: T�be Contrartor:c (Conc.)(Masonry)(Weldingl Licexsv Lau�doe.��not apply Lo an owner of prnperty u�{�o � bui/ds or i»:psoi�i�.c tl�ereon,and u•bo cantracts f�r sucb lot�rainage ' proje�ts u�ith a cnnarnr7or(s/liceased pursssunt to the Cnntructnr's License I.aw). Porking �� I om exempl under Sec. ,6.&P.C.for this reason . Oate Owner Approvals Dafe Inspeafor's Signature INSPECTOR'S NOTES Location (Setback&Yards) Faundatians - Slob Frame Energy Insulotion Loth/Drywall- Inte�io� Loth� -Ezterior House Number-- Correct 8 Posled final- Enfer on Front