HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (152) . �,.. ,
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WORKERS'COMPENSATION DECIARATION. . � ��` � -
I hereby affirm thal I hove a certifimte of cons�nt fo�self APPLICA'TId.N._„FO_R�BU.�LDIN�� �PERMIT �
insure,or o certificate of Workers'CampensoLor. �suronte,
or a certified copy thereof�(Syec 3800,Lab.C.) �
PolicyNo. �����7'C�dTFipany .S%�TG F�fu�J COUNTY OF LOS ANGElES BUILDING AND¢AFETY
� Certified mpy is hereby furnished. FOR APPLICANT TO FILL IN qopeEss����'.:� � � w�0i ^
QCerfitied topy is filed wiih the county building inspec- BUILDING
no�department. A��RE55 /lS3' S .PY�''�'r�' A/Z OL/rl,�
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�� /, ary G?i�3MONp �32 zia �ocnu?r
Date .Z�.S=�I Appiicanf '��'-� -���..K�4'
CERTIFICATE OF EXEMPTION FROM WORKERS' - NO.oF a�ocs. NEnaeSi /�
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT I CROSS ST. .,_, Wv�
(This section need not be completed if the permit�s for one ASSESSOR
.hundred dollars(5100)or less.) TRACT BIOCK LOT NO. MAp gOOK PAGE PARCEL
P 7EL '
I tertify ihat in the performance of ihe work for which this OWNER�tf�J�IS� /Z�'IP .Np_ USE ZONE NOP 9 1 �
l L
permit is issued,I shall not employ any person in any manner SPECIAL �
so as to become subject fo ihe Workers'Compensation Laws. /+DDRE55 3.Zf ,� �Gs CONDITIONS V
._ - , . . .. CITY ��S(G/� (J�LE C'� ZIP �I��7 z ` `�'f� �
Dafe Appiicont A2CHITECTOR tE�- DIS7RIQ G FIRE PROCESSEDBY �
NOTICE TO APPLICANT: If, after making this Certificale of ENGINEER No. �
Exemp�ion, you should 6ecome sublect to ihe Workers' . . . CONST. ZONE �n �
Compensation provisions of�he Labor Code,you most forlh- qDDRE55 1 Q � \`��� �
with comply wifh wch provisions o� �his permil sholl 6e' -'- '�-- - --� �TEL. �ti STATISTICAI CLASSIFICATION ' APT. CONDO. �
deemed revoked. CONTRACTOR C t��L N/� F/12�C n�0. +d"/f dr -
LICENSED CONTRACTORS DECLARATION � LIC ��� CLA55 NO. DWELI.UNITS
i hereby aRirm fhot I am licensed under provisions of Chapter 9 ADDRE55 ��'��G'0/�/ }'T-R�G�NO. YjGI�a� .
(commencing with Section 700D)of Divisian 3 of the Business and LIC. �- �� �� ��R�P
Profiessions Code,and my license is in full forte qnd effect. CITY CJ�/Z ! � CR. CLASS C,/ : gK PG VALIDATION
a ` SQ.Fi. NO,OF NO.OF CHECK
Litense Number ��Z�/ Li[.Gass,G"/�" SIZE STORIES a� FAMILIES d NE�NE yA�UATION c 3,� � .� A
DESCRIPTION OF WORK �6
Contractor�'G�C/ELs'1y`r/..1 f�'/l�'p`pte /D=Z7� � S js0�� ,
_,_. T�'�'//} IC //2 L� .S�P/2//Y ADD 7T• o F 5 2 v
�I am exempt under Sec. q��R � ^a
B.BP.C.for this reason S�f�C/vY REGAIR � S����17 � `�'9��3�
Date: USE OF O DEMOL "C
y� EXISTING BLDG. C M/�' o '> ��`�/j>v S t.=i
Si�nature�� l ����"� APPLICANT TEL. 'y�Y FINAL
9 � PRINT)yy�i.�-E- CL I/ L N.DNO..(yr1^NS.�? DATE I O.G I"H L`
OWNER-BUILDER DECLARATION . .._ -- ..
I hereby affirm ihat I am exempl from ihe Conirdcror's License qpDRE55�y'� l��N S� �£/zS//.?C' f.�—
Low for fhe following reason (Section 7031.5, Busineu and FINAL
Professions Code): PRE gY '-,?�O,l4�1
❑ BUIIDING ��� '
I, as owner of rhe property, or my employees with ADDRE55 � z .
. ___ .... ..
wages as iheir sole compenwtion,will do the work and 4F° ° �L v
ihe siructure is not intended or of4ered for sale(Section LOCALITY
7044,Business and Professions Codej. MOVING -� � ---" 7EL. ' � � f � e�7.1 �
� CONTRACTOR N��
I,as owner of ihe property,am exclusively contracting � r� —
' with licensed contractors to constrvct the project(Sec- � \j ° ' �G%.i ��..
'�on 7044,Business and Professions Code}. ADDRE55 �
REQUIRED YARD HWY TOTAlSETBA M I � � j j,'� ,?—�p
" CONSTRUCTION LEIJDING AGEIJCY � SE7 BACK PROP.uNE WID7Fi
�Ihai there is a construction lending agency for FRONT -� S
-e of the work for which ihis permil is issued P.C. - - � -b.,O J�4
".). SIDE c c
r^�Z��T/Z/� ��/�rC'�fi�/�'V" P.L . is �
� .7 .�o IDMA Ref.p . , •;
3�O G/9 �'L f� %0'G�-.�/2, P.c.Fee s . , ce,mn Fee __.... ' 1 � ! 4 i,D G
I�n� � ic s
f�opplication and sTat�1 af the �� e�] Iss�ance Fee � ���4 P�C� � Q f S n�`
:'��gree to comply with all County Investigation Fee j I. i �',,��'(�
•elating to building ronstruction, . To�of Fee �� `� LDMA Perm.#
•ntatives af this County to enier
�eriy for inspection purpases. . ..... . �.�-..-.-.�...... .. . . .......�: .
'/��jP��'��� SEE REVERSE FOR EXPLANATORY LANGIIAGF
Dare
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� - _ .
�LANS TO APPLICANT INSPECTO OTES OLVNER-BUILDER DECLARATIOv
!hera:'y affirm thal I am exempt from the Contractor"s
To: Returned Licens�'Law for the following reason. �Sec. 7D31_Sj
� Approved 13usin.ss und Projessions Code:Any city or count,y whu'b
No. Date No. Date require.c a permit to consEruct,altcr,imprnre,demolisb,
'orreyair an1'structure,prior ta its issuanre,aG�o reguires
tbe ut plicana fr�r suc5 per»z(t to file a sigxed statement
zbat be is licexseG pursuant ta the prn ns nf the Cun-
lructnr'.�I,icense I.am(Cbr�A�cr 9J(cammeneioig witl�,Sec-
tro�7000f of Divrsion 3 of tTie Basiness aaid Professions
CadeJ nr abut he is exempt tbere.Jrom and tl e basisfor tbe
ulleqed exemption.Any vinlretion uf Scotion 7031.5 hti'
Required DaYe Reeeived uny¢pf�licant for a permit subjacts.the applican[en a rir�i!
Approvals a�pPP�ovad � penulty af not nenre lba�/ine Aurulred do!lurs(5500).J:
Yes No
�_ I,os owner of the properfy,or my employees wi�h
Water Cenificate � wages as their sole compensotion,will do ihe work,ond
the strudore is no�intended or oftered for sole(Sec.7044!
Heahh Depariment_ Bas ne nnd Prnjessinns Codc:T! Contrurlir's I,icense
l.aw dnes not upply tn an ou�ner nJprope.ay u•5�,bui[ds
Pire Depariment nr rmprnres lFrereon,und:uhn doe.r sueh wnrk bimsn[f r r
througfi brs ou;n e�layees, prnniJed abat aach im-
Grading prnvements are nof intended or offemd for sule. /(•
homever,tFie buidding or r»:provement is so1J u•rtfi[n one
� Geologlcal � year n/completion, the numcr-builder will hare the
, fiurden�i prnz�ing t/at be d'u!not huild nr inopmve(or
Pedestrian Protectian tFie purpase oJsaleJ.
(Fence)(Conopy) J �,ds awner of the properry,am exdusively contrao-
" �ting�wiih�licensed contractors to consi�ucl ihe projecl(Se<.
Special Inspection 7D441 Busine.as and Prnlesseons Code: 7'be Coxtructor'.s
(Conc.)(Mosonry)(Welding) _ Lecense Lew does not apply to am owner of properYy who
buJlds nr imprnres lherenn,and uho cnntructs for suc5
Lo1 Dra�nage � � �proJecis with u cnntractor(.c/lrcerosed pursuunt to tbe
' Contructor's l.icense I.au�J.
Parking � � -
J I am exempt under Sec. ,6.8P.C.for this
reason
' 'Dofe Owner
Approvals Dafe Inspector's Signoture
� INSPECTOR'S NOTES
Locolion—.
�Se1bo<k 8 Yards)
Foundations
Slab
Frome
Energy Insulation .
Lmh/Drywall-- - � -
Interior
Loth--Ezlerior .
House Number— ' � � - � - "
Correct&Posted � -y .
Final. . . . - , .
Enier on Fron1 ��