HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (141) __----_.._...-- -...--- ---......_-- . --- �---_--_ - ----:��.
WORKERS'COMPENSATION DECIARATION /'�
I hereby affirm that I have a certificate of consent to seff
insure,oracertifimteofWorkers'Compensation�n5�,a��e, - APPLICATlON FOR BUILDING PERMI J,
or o certified copy thereof(Sec.3800,Lab.C.)
1 _ COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNa:'�.' �'��.'�..t:'�¢ampany t"�.F���T-'l.i:`�i a � .
� Cerrified copy is hereby f�rnished. FOR APPLICANT TO FILL IN Bu��e�rvG
ADDRE55 �/i i i'. :j,
. � Certified mpy is filed with ihe couMy building inspeo- BUiLOiNG . � -
tion departmenl. •^ ADDRE55 � ;-�{.-�>
�:;f.
�;f, r��,�{'l ��:. �� !:�� CITY �. ".>'��,r_'IP LOC�A!ITV ' '/1 s .. r`J/�;i"
Date ;�,' �, -Applicaryv f ` -+"'�' . -
CERTI�EXEMPTION FROM Wq KERS' .No.OF e�oc5. Ne.4REST
COMPENSA?ION INSURANCE 5¢E OF LOT NOw ON LOT CRO55 ST.
� (This sec!ion need not be wmpleted if fhe permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. AMP BOOK PAGE PARCE�
TE�' USE ZONE �P Y
I certify that in the performance of ihe work for which this OWNER :l'�. ' NO. � �- 't ' �,
ermif is issued,I shall nof em lo an erson in an manner SPECIAL � � o
so as ro become subjecl to thePWorkersPCompensation Lpws. ADDRESS ' CON�ITIONS v
�
CIN ZIP '�
Date —Apolicant �'
ARCHITECT OR TE�� DISTRICT GROUP NPE FIRE PROCESSED BY
. NOTICE TO APPLICANT: If, affer making this Certificaie of ENGINEER "`� NO. - �
Exempiion, you should become subject to fhe Workers' w CONST. ZO,NE , '�
Com ensation ovisions of the Labor Code, au must forih- . � � �!` �r =�"- a
p Np� Y ADDRE55 - �'-% OC
ifh compiy fh such provisions or this permii sholl be TEL STATISTICAL CLASSIFICATION ' APT. CONDO. �
w '
deemed revoked. " �"i't�L�?!J • d
CONTRACTOR '--: ; NO.�� _
UCENSED CONTRACTORS DECLARATION � LIC. � CLF55 NO. DWELL UNITS W
!hereby affirm that I am licensed under provisions of Chapler 9 ADDRE55 i,�.;S !� ` -.•�'-•a----•NO."%id'::`�`" �yyER MAP ~
(commencing with Seclion 7000)of Division 3 of the Business and LIC.
Professions Code,and my license is in fu�l force and effect CITV [„ C1A55 � �?'� gK PG VALIDATION
r � Sq.FT. �- NO.OF NO.OF CHECK
License Num6er,1 �-:%"�.� �.f�r Lic Closs '�� '� 'Y' � SIZE SiORIES FAMILIES ONE
VALUATION
'^.'Pt:/✓ ,�..^,.•'.' :, _�„+'' ' �'•-_ DESCRIPTIONOFWORK ` `: .' 7 .:l,i, ,-` °
/ NEW
Contractor : � :.- �Fil�e �,.' " S "�ff � ""
. ��f���� ADD ❑ A , :".t•'.�..'.`.`. S:
�I am exem t under Sec. ?�'` ? 'f�-f`s � ;' � _ .
ALTER
❑ '.6 a 4 a!,'.F`
B.&P.C.for fhis reason f.,. � � REPAIR § � ��'���
USE OF r '
Date: . EXISTING BLOG. DEMOL ❑ ,�( s,a�S'�..f.���
Signature APPLICANT ..�, NO. .. - FINAL o 4 c r r�:w'.
OWNER-BUILDER DECLARATION PRINT) DATE �-`�
I hereby affirm that I am exempt from the Coniractor's License � _,,rj y-:�'.��
Law for the following reason (Section 7031.5, Business and ADDRE55 � t '�'�-. �... .FIWAL � � �
Professions Code): PRESENi B'1
OBUILDING
I, as owner of the property, or my employees with ADDRE55
wages as iheir sole wmpensation,will do the work and
the structure is not iniended or offered for sole(Section LOCa.LITY � ;
7044,Business and Professions Code). MOVING TEL. ' . �`"�4''�����r�'
� I,os owner of the properfy,am exclusively controcfing CONTRACTOR NO. Ay.��,i.'a.�.� '.
with licensed contractors to canstruct the project(Seo qDDRE55 ��
tion 7044,Business and Professions Code). a c s,,°.�;';
RE�UIRED TOTAL SETBACK FROM I `- ��'�'
CONSTRUCTION LENDING AGENCY SET BACK YAR� HWY PROP.LINE WIDTH . . .
I hereby affirm thot Ihere is a construciion lending agency for FRONT +i?'.!'�,i �,!;�'.�+
the performcnce of ihe work for which this permit is issued P.l. . ,
(Sec 3097,Civ.C.). SI�E �.(�,�i"^�,j',s,:
P.L.
� Lender's Name
8 i''.�� �r . LDMA Rei.#
l ,. P.0 Fee S Permit Fee
- Lender'sAddress r " ,-
>
I certify thot I have reod this applimtion and state thai ihe Iss�ance Fee LDMA PiC N
¢ a6ove information is correct.�agree to comply with all County Inves�igation Pee
ordinances and State lows relating to building construction, To+ol Fee �DMA Perm.#
D� ond hereby authorize representafives of this Couniy�o enter
Q - upon,ihe'above-mentione�F property f0�inspecfion purposes. � �� � �"��- � '��� �-� � �-
a ../= l, ` ', J' ''r y�
;�„/ � ��f C''-',�f �',r ,...r,,.}�=�>':'%!�J '� SEE REVERSE FOR E%PLANATORY LANGUAGE
� Slgnaiure of Abpl'ican or Agenf '�� n�
I
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