HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (122) - ___.. __.__,� . _,__ - -.- -
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WORKERS'COMPENSATION DECLARAiION ��� ��
ww. . . . . . . .. _ ..� .- -� . , . . .
I ere y a irm i ai I ave a cerfificote of COnsent lo self H�Y�' ATtON FOR�����BUI�L�DIN�G PERMIT
'sr.sure,or a certifica�e of.Workers'Compensation Insurance, 0
or��eerti£iedcopy thereof(Sec.3900,Lab.C.) COUNTY OF LOS ANGELE$"� BUILDING AND SAFETY
PolicyNo. Company �
Ceriified co is hereb f�rnished. 6UI!OING
❑ PY Y FOR APPUCANT TO FILL IN nooeess �f S�S— S, te�E�r !//1-- �'
t-1 Certified copy is filed with ihe caunty 6uilding inspec- BUILDING e'
L� tion deparfinenf. AD�RESS { �' OCALITY .
s /
Date Applicant CITY � ZIP f �C ~ CROSSSST. Y/.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. F BLDGS. ASSESSOR ✓
COMPENSATION INS�RANCE SIZE OF LOT NOW ON L07 MAP BOOK PAGE PARCEL
(This secfion need not be completed if the permit is for one USE ZONE MAP / , ' �^
hundred dollars($100)or less.) rkqCi BtocK � NO. / ` J�,.1
'L . �^� SPEGIAL *y.
I certify that in the performance of fhe w f •which ihii OwNER �y " � 0. �- CONDITIONS �
permif is issued,I shpll not employ any rso -i p y manner � .o--. DISTRICT GROUP TYPE FIRE GROCESSED BY J
so as ta be m subjact fo the Worker ,.Q'o ns ' L y, ADDRE55 � P�� � � CON�S� ZO `Q:
f '- �' 'S5 � l' r� �- l�� ��'� �� °"'�- a
Dafe / Applican � ARCHITEC70R� ' ZIP 7E�, STATISTICALCLASSIfICATION` APT. CONDO. �
NOTIC TO A L CANT: If, aher mal g t st i e af �/'� � —^ �
Exem ion, yot/ should become ject the Workers' ENGINEER , NO - QASSNO. �.�7 DWELL.UNITS• w
�
Compensafion provisions o4 the L r Co ,you must forih- qDDRESS sCj SEWER MAP �
with comply with such provisions or if�is permit shall 6e TE� �
deemed revoked.
CONTRAQOk , ,i�"ti NO. BK. PG, VALIDATION
LICENSED CDNTRACTORS DECLARATION � � LIC.
I hereby affirm that I am licensed under provisions of Chapler 9 ADDRE55 NO. VALUATION
(commencing with Section 7000)of Division 3 of�he B�siness and ��C. �G��.�
Professions Code,and my license is in full force and effett. CITY CLASS 5 �-/E�r�1 ►
SQ.fT. NO.OF �NO.OF CHECK�
License Number Lic.Class SIZE STORIES �FAMIliES � ONE
.-- � s ��43.3F,
DESCRIPTIDN OF WORK NEW
Conirpcfor Date ADD �e � e �C v
❑I om exempf under$ea � AL7ER ❑ FINAL '`�
B.&P.C.for ihis reason ,f REPAIR � DATE �-7 r?�; � r =2 5,��
�ate: USE OF DE OL FIN/)Ly. � G � �'c ti,v'�.;'c=i
EXISTING BLDG. GF /� /� ❑ By� .
Signature A.PP�ICANT 'TEL. I i.0 6—8 6
OWNER-BUILDERDECIARATION PR�NT .. �{�' �n� ,
I hereb affirm tba�I am exem 1 from the Coniractor's License /� G� � '
Law for the following reason(SeUion 7031.5, 8usiness and ADDRESSi +� L�' �� G �
(jrqfessions Code):
f1fl BUILDING
r � I, as owner of the property, or my employees wilh AD�RESS
�� wages as their sole compensation,will do ihe work and
the s}rutture is not intended or offered for sale(Section LOCALITY
7044,Business pnd Prafessions Code�. MDVING TEL.
� I,as owner of}he properly,am exclusively confrociing NTRACTOR NO.
with licensed contractors to consfrucf ihe project(Seo qooBE55 '�.�y,� F
fion 7044,Business and Professions Code). ��
REQUIRED TOTAL SETBAIX FROM EXIST. e 1
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH 4� o m o
I hereby affirm ihot there is a consfructian lending agency for fRON7 �
the parformance of�he work for which this permit is issoed RL ( .c o�p�5
75ec.3097,Civ.C.). SIDE
- P.L.
Lender's Nome � ° `%�� �5"-*�
$ P.C.Fee y �.5��-�'�J Permii Fee �(:s � ( 1,1 7—8 6
Lender's Address
� I certify that I have read ihis application and state that ihe Issm ce Fee � x`'�
� above information is cortect.I ogree to comply with all Couny Invesiga�ion Fee �
ordinances and Stat laws relating to building consiruc�ian, io�ol Fee
and hereby r'e r �resentatives of this County to eyyyn���ter
� upon fh ve- enti d p perty for inspecf n �s.
��e
� ? � SEE REVERSE FOR EXPLANATORY LANGUAGE
��re�f pli or Agenl Oate
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