HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (124) WORKERS'COMPENSA710N OECLARAiION� � I hereby oHirm thqt I have a Gerlificate.of mnseni fo self ,App`fCAT10N FOR BUILDING PERMIT insure,or o certificate of Workers'Compensation Insurance, � �,;: or a certified copy thereof(Sec 3800,Lab.C.) COUNTY OF LOS ANGELES BUfLDING AND SAFETY „.,��; -:'._ ;,'•', Policy No. Comppny -' - , „ , ❑ Certified copy is hereby furnished. FOR APPLICANT TO Fill IN aooaess 1�...; '`^•% ` � r BUfLDING � '"��� � G� Certifled copy is flled with the county building Inspeo- j<<_;;�; f',/�,��•'!�'•'i �� r'�"� ADDRESS tion department. . - `, , . �:� .� an '' `� zia ca�sv . .. .'r'- ''�F LO �Date ' � Appliconi `' '`�'�� "�'� '� NO.OF 8LDG5. NEARE T - '' CERTIFICA7E OF EXEMPTlON FROM WORKERS'� _ 5¢E OF�OT NOW ON LO7 �p�g7. ��:'E j.> . COMPENSATION INSURANCE ASSESSOR (This se<tion need noY be completed�f ihe permif is for one TRACT BLOCK lOT NO. MAP BOOK PAGE PARCEL hundred dollars{$100)or less.) � � -- TE�� USE ZONE MAP ' OWNER fl:.' . �.�F� :. NO. NO. f''?' � '/ � 1 certify ihat in ihe performance of the�work for wh�ich this SPeCiqL permif is issued,I shpll not employ any person in any manner ADDRE55 '" '�i CONDITIONS � � so as to 6ecome subject to the Workers'Compensation laws. e3. CIN Z�P O Dafe Applicant ARCHIlEC7 OR TEL DISTRICT GROUP TYPE RRE PROCESSED 6Y �NOTICE TO APPLICANT: If, after making rhis Ceriificaie of ENGINEER NO. CONSL � Z�NE � Exemption, you should bemme subject to ihe Workers' .�. �-� �+- � "Compensation provisions o{the Labor Code,yoo must forth- ADDRESS ���� r with comply wifh such provisions or this permit shall be � i - - ;�_.rTEL, .,t ,:. STATISTICALCLASS!FICATION '� APT. CO O. � deemed revoked. CONTRACTOR`.L. °NO. • ' , Q UCENSED CONTRACTORS DECLARATION �� ' '.�j;�'���.��. No ,;.,,. '~'��f�y, C�A55 No. �"y� DwEL�.UNIiS O ' I hereby affirm that 1 am licensed under provisions of Chapter 9 ADDRE55,'`:� �' '� o- `�C, SEWER MAP � (commencing with Section 7000�of Division 3 of the 8usiness cI7V �� �'' - �� '� ' � CLA55 '- ��-- VALIDATION � ond Professions Code,and my license is in full force and effect. �, BK, PG, E'" . �._,, SO.FT. NO.Of NO.OF CHECK `� � �.�. 'r'� SIZE ��.er S70RIE5 FAMILIES ONE License Number - Lic.Class �� -- VqLUATION ' ` �`�'+""�,.-�i+��/ DESCRIPTION OF WORK . NE�N � S f�� r}; Coniroctor��-� �% " < ! Date � ► ��•,. � p . 'y�r.� - ADD L� �..,f.,t; . ❑I dm exempt under Sea h ,4f ALTER J ,,t : r—� s a¢ r,_..� 8.8P.C.for ihis reason ' REPAIR L.� �` .�.p Date: EXIS�NG BLDG. DEMO: L1 �.'�,���f:,^''�u C` APPLICANT TEL. f' m n�e���" �.r.`� Signature (PRINT) . "�+' "- .,%�=� NO. . .: FINAL , ....H•. ... OWNER-BUIIAER DECLARATION ' DATE �� .• � I hereby affirm that I am exempt from the Contractor's License '�;�;��,. r�;;'_'��: , '.y'.� :'�'°�;.":W:��''. Law for ihe following reason (Seclion 7031.5, Business and ADDRE55 � FINAL Professions Code): PRESENT By —.. ❑ I, ps owner of the property, or my employees wifh qppRE55 . wages as their sole mmpensaiion,will do fhe work ond �pCALiiY , the structure is not infended or offered for sale Section ,- ' 7Dd4,Business and Professions Code.) ( MOVING TEL �,.v(r;j.i�Y. CONTRAC�OR NO. , � � I,as owner of ihe property,am exdusively mntraciing � wi}h licensed coniradors 10 canstrutl the projetl(Seo- qD�RESS y � n,¢_wi a '�, tion 7044,Business and Professions Code.) gEQUIRED TOTAL SETBACK FROM EXI57. J.�'�;�,.�'C.,��'. CONSTRlJCT10N LENDING AGENCY � SET BA K vARD HWY pR P.LWE WI�TH I hereby affirm ihat ihere is a cans}rudion lending agency for FRONT ^.u.�',a's�,r'r the performance of the work for which this permit is iss�ed P��� �- , ..� (Sec.3097,Civ.C.). SI�E ,p."j� �'`.�^^��'.�;. P.L. Lender's Name LDMA Ref.R P.C.Fee 5 ,,.� - Permir Fee .� � �- Lender's Address � ' Issvance Fee - ' { LDMA P/C A , ' " I certify ihot I hove read ihis application and sfate thot the � 3 obove information is corred.I agree fo comply wHh all County Investigatian Fee '�,�� / ordinonces and Sfate laws relating to building consiruction, To�al Fee c>`�'�� �' LDMA Perm.N i and hereby a�thorixe representntives of ihis County to eMer ' upon ihe above-menlioned property for inspeciion purposes. x . � '% SEE REVERSE FOR EXP�ANATORY LANGUAGE � � Signanre of Applicani�or Agenr Dale ' . ,. , . . .- .. .__...--�s - . . .. . , .. �.� . _ ' ;--r-.. . ... __. ...._,'=---�—'—'_-.�.xK.:�.�,.....a;.+.--c:>,.....,-.-s:.._._....._.._._...._..................._. ..._ . .. - . ,..,�_i4�•�. - .. ... ,.:..,..�'_�. .............. :.'::T��t�v'� � . ' ..'..- � .-, e. ., :. � .:i,,. :.� . . '.:.- ' , _ . .. �. . . �. .: ,,. ,... y ., .. . . . � . � . ../a.J ��':,: _ . . 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