HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (151) VJORKERS'COMPENSAiION DECLARATION �171-'��
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I herc�Dy affirm that f have.a rert�fimte of mnsem to self . AP�'�LICATi_�d�V����4�R ����L�IN-G PERMITg �e
insure,or a certifimte of Workers'.,ompensation Insurance,
` or o certified mpy ihereof(Sec.3800,'La s.) �, BUILDING �� � � '�
.-�1 Fi COUNTY Of LOS ANGELES BIJILDING AND SAFETY ��""�'�
P❑ollcy No. z �u Company �- �
Certi£ed copy�s hereby furnished � FOR APPLICANT TO FILL IN AD�RESS � �1� ��-�
� Certified copy is filed with the munty building�inspeo- BUILDWG � n�� � �� �� � -
ti n deptlr}ment. L�. ..�,e_ 7 ADORE55 �/,js �' (, � � �
'� �' ' .. C�'J�^ �YLC J'-' . . ...__'' '___
.�Date PPlicant � CITY ZIP LOCALITV �����"-' ' - '��
� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF 6LDG5. NEAREST . . .
� COMPENSATION INSURANCE � SIZE OF tOi NOW ON lOT CRO55 5T.
(This seciion need not be completed if the permit is for one ASSESSOR -
hundred dollars($100)or less.) TRAQ BLOIX LOT NO. MAP 000K PAGE PARCEL
- TEL USE ZONE MAP
I certify ihat in the performance of the work for which this OWNER�'.K V NO.��S���'3� Np. pJf�3 y�� }
permii is issued,I sholi nol employ any pe°�on in ony manner � SPECIAL Q.
so as to beco�m_e su��bject io fhe Work rs'ybmp n fion L� ADDRESS C s ')fir-s � CON�ITIONS o
� 1 CI7Y Z�P pg
Date r n " ARCHITECT OR � TEL. O
NOTICE 70 APPLICANT: If, afler making this Certificafe of DISTRICT GROUP TYPE FIRE 7R04ESSE�Bv F
ENGINEER NO.
Exempiion, you sho�ld become su6ject to the Workers' _ / CO ST. ZONE A„ � W
Compensation provisions of the Labor Code,yoo must forth- GJ ,9 0` O.
AD�RE55
ifh comply with such provisions or this permit sholl be - - �- � ������� �y� � H
deemed revoked., CONTRACTOR �--/ STATISTICAL ClASSIFICATION APT. CONDO. �
S/GNSNO. '
LICENSED CONTRACTORS DECLARATION uPe:�tIC. �/ 'r CLA55 NO. �v oWELL.UNI75
I hereby offirm thaf I om licensed under provisians of Chapter 9 ADDRE55 �''J NO.-T 7'�{�`J'�
(commencing wi�h Secfion 7000)of Division 3 of!he Business and ��� �- �/ - SEWER MAP
Professions Code,and my license is in full force and�effect. Ci7Y -� O/�!.r�' CIASS C�/S BK � VALIDATION
`,�}-.^ /�,.� SQ.FT. � NO.OF NO.OF CHECK
License Number�'�`7^F� lic.Class VT� SIZE S STORIES FAMILIES ONE
� VALUATION
���_ �l ��1-�-y?� �ESCRIPTIONOFWORK J�G NEW �
� C❑ontroctor L,!GT..�Y�C• �.('� Dafe ... .... . s - ADD $ I G?O fJ•OG? , z(,�]L'.�'y'
I am exempf under Sec y�� � !V�
_ ALTER � .-, d P � 'G O
B.&P.C.for this reason , REPAIR � ; C
y Date: USE OF ❑ � r' °��'C C
EXISTING BLOG. DEMDL
APPLICANT TEI.P��j F ' `�C 4'U��
Signature � �s , FINAL
PRINT) J,�:J%{ NO. 1�ZS�
OWNER-BUIIDER DECLARATION . DATE
I here6y affirm lhat I om eaempf from the Confractor's License � u y. I 7."(�''��n
Law for the following-reasdn(Seciion 7031.5, Business and ADDRESS �� ��' �11 r /�7 FINAL
Professions Code): pzeSeNT - - � gY
❑ BUILDING ,
I, as owner of Ihe property, or my employees with ADDRE55 . _ . _.,_ ._, ,
wages as their sole compensation,will do ihe work and �Q�q�iTY , �
ihe structure is nat intended or offered for sale(Section
7044,8usiness and Professions CodeJ. MOVING TEL.
❑ CONTRACTOR NO. r
I,as owner of the properiy,am exdusively contwcling (��1 �.�3 9.4 A
wifh licensed coniroctors to wnsiruct the project(Seo- �g i
tian 70d4,Business ond Professions Code). ADDRESS f f �m �,� i��
CONSTRUCTION LENDIPlG AGENCY � REQUiRED TOTAL SE78ACK FR M X t. ►�
SET BACK �ARD HWY PROP.LINE WIDTH ' o e 3 a 5 6
I hereby affirm ihoi fhere is a<onstruction lending agency for FRONT
the performan<e of the work for which ihis permit is issued � P.L � o m V =
(Sec.3097,Civ.C.). SIDE Q J�Q c�
P.l.
Lender's Npme 0�.2 2".�7
¢^ LDMA Ref.H
W Lender's Address � P.C.Fee$ �y v � Permi�Fee Q � ' '
> C(�
I cerfify ihat I have read 9his application and state Ihat the Issuance Fee ��.J�! LDMA P/C N '
obove information is correcL I agree to mmply wi�h all County ��vevigation Fee ' A
ordinonces nd State laws relating fo 6uilding construction, Torol Fee �3, LDMA Perm.M
m °
i; and hereb�thonz represematives of this County to enter
� upon`� ve-m nti ed properiy for inspection purposes. ' � - -
a ���7�`��.�. ���.�)��� SEE REVERSE FOR EXPLANATORY LP.NGUAGE
0
Signature of Applimnt or Agent Dote ' '- " ' ""' '" "'
I ' '—,�,�"""___"__-�..__. .._..-`.,�"`•--_.»..».......,..-.�.._.o..-.,�-.A.a_
PLANS TO APPLICANi - INSPECTOR'S NOTES OWI�F.R-$UILDER UECLARATION
I hereby affirm�hat I om ezemp�from ihe Coniractor's
To: Refurn¢d License Law for the following reoson. (Se<. %031.5)
Approved Busixess and PrnfessFons Code:AnY city ur rounty u�hicl
No. DaTe No. Dpfe requrres a permit fn cnxstruct,alter,isnpmx�e;demnlisG,
. or repuir any stnaccare,prior to its uauance,also requires
tAe¢pplicunt jor aucb permrt to fi7e a siqnvd statemeret
thaz!e is licensed pursuunl to dAc prnnisians�f tbe Co�-
tractnr's I,i<ense l.au�(Cbapter 9J(cwnmencing with.S¢c-
• tian?0001 q(Draisinn 3 of tbe IIusireesr urod Prn(esrione�
CndeJ.ar thaa be is exempa tfierefrnm and tfie basisfnr dbe
ulleged exemption.A»y:�inlqtion of Secaiox,703I J by
Required Date Received - uni'aAPlicanL jnr a permit subjecas the applicant tn u ciril
Approvals or Approved penulty j not moro than�'x:e bundred dnllur.c(.SS00/.J:
Yas No
Ll I,os owner of�he property,or my employees with
Water Certiflcate wages as their sole compensafion,wJl do the work,and
the srructure is not Intended or offered far sale(Sec.7044)
Health Deportment dusiness anJPmfessinna Coder Tbe Contructor's License
I.aut t6oes not apply to ua owner qf Property wbo builds
Fire Department . . or impro:!es fbereon,and whu does sucb work 5imselJnr
tbrnugb hix ou^n employees, proi!iderl tbat such im-
Grading ' � pm:�cmexts are aot intendeJ ar n(Jered for xale. If,
�- � bn:uever,tbe buildinA ar imprnvement rs sold u�rtbi�re nne
Geological . yemr oj rompletion, tl�e oxuner-6eeilder wi71 haz�e abe
burden of pmnan,p that fie did nnt buifd nr iraprovc fnr
Pedesirian Protec�ion ' tbe purposa of.vala/.
(Fence)(Canopy) � ❑ I,as owner of ihe property,am ezclusively conhac-
iing wihh licensed coniroctors to conslruct the project(Sec.
Special Inspection � 7044)Qusiness aoul Prnfessin�ns Codc:Tbe Cnntractork
�Conc)(Masonry)(Welding) . l,icense I,aw does nnt app[s tn un owner nf pmperty wbn
hui7�or inapraves tl ereon,and whd contracts fnr sucb
Lat Droinage - prrrjeus wie5 ¢co�tructor(eJ license�d pursuant to [l�e
CanEructor's L,icettse l.au�J. . .
Porking r I om exempt under Sec. ,B.&P.C.for this
reoson
� Dote Owner
Approvals Dofe Inspsctor's Signoture
INSPECTOR'S NOTES
Location--
(Setback 8 Yards? � �
Foundations � .
Slab
Frome '. - � , -
Energy Insularion .
Lath/Drywall
Interior
Loth—Exrerior � �
House Number— - � �
Correci&Posfed
Final..__ . . _ : . . . ... . ....:. ...:..��. -.
Enter on Front