HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (132) WORKER$'COMi'ENSATICzN DECLARATION �
I hereby affirm that I have a teHifimte oF conseM�elf qpp`ICATION FQR BUILDING PERl1�AIT a�
insure,ar a certifimte of Workers'Compensation Insuronce, _ � . ��
or a certified copy thereof(Set.3800,LoblG} y�-
r ..-_ � fQUNTY OF LOS ANGELES BUILDING AND SAFETY vL
Policy Nd�j���OC�om�p ny a . -�h'1 -
❑ Cerrified copy is hereby furnished. F012 APPLICANT TO F�LC IN � T aooaess lf�s ��-�'+-�.� ��' �y"`��
❑ Certified copy is filed ith th$cou bui mg nspec- � BUILDWG J ` ,
�L#_1. 'on depart ent. ,y,rJ'J,', � ADDRE55 / ^� � �Me;:u�/� �`F'� �.�•
Date Ap ic !-"p�" cITY ,�-'d'7�i. ZIP !' L; LOCAIIry
� NO,OF BLDGS. NEAREST
CERTIFICATE OF MPTION F M W 5' SIZE OF LOt NOW ON LOi CROSS ST.
COMPENSAiION INSURANCE ASSESSOR
(Thls�section need not 6e completed if the permii is for one TRACT BLOCK LOT NO. MqP BOOK PAGE PARCEL
hundrad dollars($100)or less.) _ rE�, _
OWNER���,;,.� j NO � � USE ZONE MAP j
No. d f- �#�
I;;rrtify ihat in the performonce of the work for which ihis -�� �,tqiy SPECIAL }
permii is issued,I sholl nat employ any peBon in any manner ADDRESS Q -- . .y� ( j 1 CONDITIONS d
so os to become subject to the Workers'Compensation Laws. > f„r � � O
ciry .let✓°�9ts'f' l�r � zia !?� v
Dpte ApplicqM ARC ITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BV �
NOTICE TO APPLICANT: If, afrer making this Cenificate of ENGINEER NO. CONSi ZOI� �
Exemption, you shoold become subiect to ihe Workers' ' - �<�, (? .� �",'�,I (� U- V
Compensation provisions of the Labor Code,you must forth- noDRE55 �� V V ,�- a
wiih comply with such provisions or this permit shall be � r�� F„_����f� 5rqn5nCnt cu+55iFiCnnoN APT. CONDO. Z
deemed revoked. CONTRACTOk '�E '�f�-•� !� �NO. ev
LICENSED CONTRACTORS DECIARATION uC. /-�f'��p� anss NO. =��-�we�.uNiu
I hereby affirm ihat I am licensed under provisions of Chapter 9 ADDRE55 ��:���^ � �✓NO�(;^�GG�'Y�
,/ ��� SEWER MAP
(commencing with Section 7000)of Division 3 of the Business CI7Y uh" �JG�t. CLA55 -
and Professions Cy�1 e,and my licery5 e is in f�ll 4orce ond effect. gK, pG VALIDATION
'°J J y�/�/ 54.F7. O.OF NO.OF CHECK
License Number�"<<G "��G Lic Closs� SIZE STORIES FAMILIES ONE yA�UATION
Con+racroF[-�`�hti'4��"�ICi"�p�e oEscRiarioNOFwoRK N�^r S aY �rr7��
> ADD i
❑I am exempt under Sec Z� ' ��+�����'`? E'�"'"�"t^'S' - t��
ALTER •- . ' +�?
6.8P.C.for ihis reason REPAIR❑ S �i � ,� '
Date: USE OF � `-"
� � EXISTING e�DG. DEMOL❑
I G vi.i�;
Signafure APPLICANT TEL. � FINAL
OWNER-BUILDER DECIARATION f ;PRiNT) NO. _ Y
DATE %�r e :> '-�`� '.
I hereby affirm that I am ezempt from the CoMractor's License '" '-``� \
Law for the followin reason Section 7031.5, B�siness and P.D�RESS FINAL
Professions Code): 9 ( PRESENT � " ' By I ��• ; "-`"�" �
❑ I, as owner of�he ro ert or m em lo ees with BUILDING
P P Y, Y P Y ADDRE55 t(�
wages as their sole compensation,wil I do ihe work and �OCt+uTv ► �
ihe sir�cture is no�intended or offered for sale(Section �
7044,Business and Professions Code.) MOVING TEL.
❑ I,as owner of ihe property,am exclusively rontracfing �NTRACTOR NO. -`,��,�!�
with licensed coniradors to consiruct the projed(Seo- AD�RE55 \
iion 7044,Business and Professions Code.) r; ° ' � � � �
REQUIRE� TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SE7&4CK YARD HWY pROP.UNE WID7H - -
�hereby affirm that there is a construction lending agency for FRON7 � m `" ��' (�
the performance of the work for which this permit is issued P��� � � , �,�.� . �_ �'
(Sec.3097,Civ.C.). SIDE ' ``%�''•''�%�= ,�
P.L. ��; �
Lender's Nome. � I, I ,5�
- ' `L ��� LOMA Ref.#
? P.C.Fee$ ��"� Permi�Fee �7 +j -
o Lender's Address
I certify that I have read thi pp imtion and slate ihat ihe Issuance Fee ��=`S � IDMA P/C# , ��
� a ve infor�ption is correct ❑gre to mmply with all County Investigafion Fee �^-
dinonce and St low relati to bu'Iding construction, Total Fee `'��•�� �DMA Perm.N {`�f�
Q nd er outh � resentat o his Coun}y to enter , � �
. . .... -. . .. ..,�� . .. , .� �
up ove-m ed prop f inspecY' n pu�pose � �
� .� � � � (��`
� . � . �' � ,�J� �� SEE REVERSE FOR ExPLANATORV LANGUAGE �j
Signa�ure f4Applican� Agent Da�e
'-.,-.,-._.a•:wmaoa... �:.:,o.�.-�.,..a...�m._...._..�.�.._.�em„e..�„_ R�
.C..s.�dS Y�AY'Pl.ICd:3T� .. . iI�SPEC'Cf3�.'c kQeES^_._,..__�,..�.....�._T � � _ . ...Ch7i1E�-8lIILO�P,OErLARk'�1C1� �. .
���FT��� ,��__ �...,T� i herahy a:ff��Yha4 i�^,-i exemp?fireni`,iia:GorErac.a�'.>
a �e$��� � Licer.ee�lasv for t�e toilo�r.ing s�2son. (S2r.. 703Y.5;
�gd_ ^ p �gA�o,�� , ---- Businessar.d?rc°sssianSCoe+e:Anycityorsovneysa�h:c^
�__ ,�__ . . -i . , r'equi+e.;3 psr,��:es;�.const;ucz,af.er,imarcvs,@Ei7o:ish,
��o�-��— -�ax[a i�lo.' Dete � ��. ...,�. -
_.��..�___- ar rspav 2ny st+'ucture,p�ior±a iis issuanr.s,a;so:aq�+ires
� i =- —� .�� ... . - Pircx ag�3!fCa'�?1`7!a^JCI7 GcFl�:'#20 III9 3 sign�id ats?em2r.P
� �!,_ �.�,_ . 4ha;h�isiic�nsec�p�f,suan2�oi��provisionea?Phef�n�.
--�-- ' -'--'" � � tractor's License Lar�;Chapter�)!commer,cing x•ith Sec-
' � � - trnr�7GQQ}of Gi�flsicr 3�f ihe Business arsd Profeasfo:?::
�____._._._.�.. - Code;or Yha•ha is examA::he;efrom an.�'.e�e�aeFc ra�
� ._.._ , -- ?ha 31reg4tl ax2m�fmn.Any•r,'oJat%oir af Sectir:�703;.5 hy
.� . ... qy4u:rea7 ,r,aie Rer,eired/ .. .. _ -2.ny appiican.fo;a{�e;nr^uublac.s fAe apP/i!:ant eo�crvi.'
. D.pr*ara'�� or roveG ----_,... u�nelfy of not more:ra^f%v2.'+i�ndra.d dclJar>($a'G01.1:
. .._ ,_ w� �o �Pr J ❑ i;2sownsrofihepropeYy,prmyom�ioyees=ti`�P�
� �—. .,�_��__�_..-.�.-_...,_-...___._._.� wae[a5�ac N:ai�;cl��com,r,onsation,w�19 da the wc:k.anc
�W-qer Ceritficate �---� 1he s",ruciurs is�o:in4c-ndod at-c3Fers�€or�afe(S3a'1��;.
_...�_.--�.-- '-'--- .. Busineas Fnd:°ref2ss:nns��eCe:?he Co,�raatc's L?sense
-9eaikh DeparYmer�t � � S . Laev a`�es not UpptyYc an��r�Eros`,nroper:y u✓ha 6vil�is
�------- --Z,_ ._..�., ._, . ----,-_ . nrim.prm�siha;a�n,a,:d.vhoa�oess�ishxo:k.hims=lfor
i,;rc Depzrtmers ' � .hroug.", hls,���v,��?mp:oyees: pn�vide�l ihat such e,n-
- � - _ . Nrove;rssnts a;e a�!i!teaded a!?!/e;s•C Vor sale. 7f;
Gr���;g h,ow.srer;:h,2 buildirg'or impravem�r,?!s so/d:?�ithi,-aha
�.. m yearo�`cum;sle°%or,,?heowner-�uitd�;::vf:h2ve"he:herde;*
'Geo�o9ic�t ' . �.� nfpravingt�ai?�ed.+d.rir,Rbulidcr;,�arovetori�her,�rcesa
�, ,., :, � _.._�� ._�...�_._.� o;cata),
Pades�r:an Prca=c��en ❑ I,2.s ownar o4!�p proR'Ny,am exc!usiaelY co:-
(���c�;lGano�Yi „�� �.-------�•------ �8!�.ctirtg vvE�fr iicenued c�r,�kractars 4o�.�cons:n,ck ehc pro-
� :s�c'(Stn:.'0�5i��srness arsc!.'rotessionr Crrle:T72 Con-
S?�acial I,seecrion ^ - -^---.__�.�.. - ._... £recfoNs!icerise Lar✓deea;;�t ao,��y io ar c�:sne:of?ro-
'iCar.c.)ilJ�e:ror.ryllY�leiding)i I . � � �ertYwhobuitdsorimprx•2sfheroor,,ar,G+vh�co.nt:acts
' _ �----.{--.._.._ - - m.._..._-V.�-___ _._,._____..__.._. __ __�. � fPr SUCh w/Of&Cts;alith a contracfolls)laGe�S�d��'urEr_�8nf
Lof 6r2inEge ,. ' . fG t.hf:CAntf-u.^�.�/'e=ir3R.S+'ie��.
Pa;;ir9� � .. . . � L1 i�cn sxarny:und€�r Sac._._..���9.&P.C.fr,r 4'.;is
�._�_�_. . ---.--
v.�
r____--`_.�._�....." " � � -�....._..__...._._.. " TH9SOfi�_�"__"'___.�____...._...�..._..__._.__...-
-�_�_'___'.-`�L� ..� ', - C�ts'_"_____._ Qwiis!
` . , . _�.._____�� �_� ._�.�..., .__.m,_._.�_
-- �GPrav�ls..�__,._.P ��saTn.-� ��easpseaor'�Slge�ature .~.�?.- - .••••...-•.--.,._�_.,. C4ASFECYCR'S�de1T�Sq.-.-._,..,.._._�......._
----=--�j '�---�� �� �.-. .,�,.___.,._�e.....,,...__._...�..___...,,� _..
Loca:ior.- ! E .. -. . . � � "'____._
;SaibaCk&°fd;dyi ,_L. _ "'_' _ __...,..�._..._._.._..�---_ �_ .
.i . ... . , _ . .
� ��ndu:ion= � ._ . . .
� Si2b _ _ __' " . �� ` -_--, _.� .. . __,. _ -___'..�..._�._...�..�._..._.�_....__....
���.� � �.
iI Prame -`----�_`--_.�/..�_U u�� � , _ , .....�.. �__�..�.._.�. , ��.._._,._
j Erergy Ensula!ion - - ---- . . ._,.-_...-._.....__.�_ . .
� `I �.____ �__-_.__:___._.___
La4hl�ryara!1- � � , _ ���
� infericr I __ — ._.._. _....��...-,..,..-..-....-.�,.,.�.�...�.,_.a._...�,._ .._ .
1 _' __�-
��Laih-�xte:�icr � .. . - . . .�_� �
Ho��siS e n;uer5er- , -_�........______. ._.._,. _`_"__. . . .
orrac��Pos.ed y_. .---.-------------^--- - � '_ -"_" .
i� �
_.�.. � �
^._�_
i- '" �- _.� .. -.. . �
f Firai-- . .... . j . . . _ .._ . .., . , . .
" Enter on�ror: � _ __..__e..__�. .�.�_�.___..-._._r. ----L--�-
�_^_-._.___ _ .
�...��._-.�.-__���.�'..__ ' � .�.... -_-...____ � .- . _ - -_.-_.�, �_..`.