HomeMy WebLinkAbout1100 DIAMOND BAR BLVD (18) WORKERS'COMPENSATION DECLARATION � - �
� he,eeY affirm fha, � ha�e o[ertifimfe o,�o�se��,o 5e�f qpp��CATlO(V FOR BUILDING PERMIT l`��� �
insure,or a certificate of Workers'Compens�ion Insurance,or �
a��j�Ji�f�ad�,osp�h�eqf(Sgc.3800,�qab.c.) ��� COUNTY OF LOS RNGELES BUILDING AND SAFETY
Po-ITcy o. �SCompany Tif���x.e%sL:I � � - ,
❑ Certified copy is hereby f��oished. � FOR APPLICANT TO PILL IN BUILDING �
. ADDRESS t, `
❑ Certified copy is filed wiih the rounty building inspeo BUIL�ING �'p/� , � � .
tion depar}ment. ' ADDRE55 ' (,s(,I � _ � LOCALITV ��„ •
Dote Applicant > �� CITY�� ZIP CROSS S7.
�:. Q`S�1
CERTIFI�COMPENSATIONOINSURANCEORKERS' ���'�" �� Npyy�ON'LOTS."C..�" ASSE550ft _
'�. $IZE Of LOT` N MAP BOOK PAG[ PARCEL
(This section need not be tompleted if the permit is for one i �� ¢�J ia )J'�P7 +� USE ZONE MAP �
TRACT �I ' {° 1,' Np/4�(m, \ � -
hundred dollars($100)or less.) , N .���T NO. � � ��s �
i TFI.. SPECIAL :
I certify�hot in thie performante af Ihe work for which ihis UWNLR f^ � � � NO. �"' �� CONDiIioNs �� � . �
e�mit is issued,I shall not em lo an y mann I � DIS7RICT GROUP TYPI RRE PROCESSED eY
p p y y person in an er � } ' '� � CONSL ZONE - �
so 6s�o become sobject to ihe Workers'Conipensation Laws. ADDRES" ,. (�[7 �. �
Date A lican� .i CI7 ' - J�P �� � ��"`^-9 p� ./
PP w Ak4 �.;;�R r � .,, STATISTICAf CLF�SSIFICATION AF7. CONDO. �
NOT.ICE TO APPLICANT: If, ofter making ihis Certi4icate of CLASS NO. � UWELL UNI�S_ �
Exemption, you should 6emme subjeU to thc Workers' ENGINEER O. . �_ �
Com ensolion rovisions of the Labor Code, ou must forlh- ~ 't � ' `n
withPcomply wi�h such provisions or }his permit sholl be � ADDRESS ��, � �y�j �� '��^' SFWfR MAN �-� �i
Tri.. /� C� VALIDATION
de�med revokocl. � CONTRAQOR ' � ,ryp. . 3_ 6K.�t� PG,� � �
� 'ICENSE�CONiRACTORS D�CLARAiION 'a •P ��� �� .
I hereby affirm that I om licensed under provisions of Chapier 9 AUDRE55 r � y�� �y- NO.".`'l+�t ��. VALUATION -
(mrnrnencinq with Section 7WU)of�ivision 3 of rhe Business and - LIC. ^^ -
Professions Code,nnd my license is in full ior<e nnd e(fect. CITY � CLr155 5 � �,,,y�d �
,,y p SQ.FT. NO.�F NO.O� CH[CK
LicenseNumber���"L d� �Lic.Class� SIZE ��� STORIES FAMILIES ONt .
Confraclor 7�P/�Elf%lN���� Date �� g
'� s�Z_�V-�+t'y.� DESCRIPiIUN OI-WORK �.'.�'" r NEW
� I am exempt from Ihe litensing requirements as I am o �+q-;�' ADD . ' .
l.4i" ^
� licensed arr.hifecl or a regisfered professionol engineer ALTER � FINAL��
. acting in my professional capacity (Section 7051, REPAIR � DATE �
Business and Profcssions Code). US[OF .a+ � FINAL � � �
� � � � EXISTING BLUG. DEMOL
Lic.or Reg.No.____�ate APPLICANT 7��.
OWNER-BUILDER DECLARATION (PRINT)��• � NO. , .
I here6y affirm that I am exempt from 1he Conirattor'<�icense � ,'} i J?�� /-J
Law for the following reason (Section 7031.5, Business and .4oDke55 _����� � "� � (,y �OS�%j � ^7/y.� .�l.:. �� � � �.
' Professions Code): pRESENi �y �� f�y f�J f / � j/'�"�f"�� ��
❑ 6llILDiNG � � ' d„{G�j.i�.Lj 6't�•i..G� .A�i.i���"-- � �
I, as owner of thn property, or my employees with ADORE55 �y . '
ages as meir soie compensoiion,wili do ihe work nnq �U�p,�IIY � / �
�he siructure is not intended or offered for sale(Section /1 � '� \ .
7044,Business and Professions Code). MOVING tEL ', /<F���r � t�` ,
� I,os owner of fhe ro ert am exdusivel conirpctin CONTRAQOR NO. �� � � � ��� '��'y'�Z,.. 'V"'�'�."'h�'` ,
P p .Y. Y 9 � . ,!�r�� ,��.S' t :
wi�h licensed confracfors to mnsiruct�he project(Sec- � f -
tion 7044,Business nnd Professions Code), A.DDRESS . - . : ] � �j''�a!� _ r}�� '���� • �� � i
� RFQUIRE� TnTAI SFTRACK fROM FXIST {���`/ YL ` � j.�
CONSTRUQION LENDING AGENCY SEi BACK Y�R� HWY pROP.I!NE WIDTH -
I hereby affirm that+here is a construcfion lending agency 4or pk(�hT , � . �
Ihe performpnte of the work for whlr,h this perml�is issued P L � . � �
/
(Sec 3097,Civ.C.1. SIDE ��f}(j;,Q j��i
F.!.
�Lender'g Name � '{:i u c� a o��
/ / 1 �
F.C.Fee$ � Pormir Fen /(�''[. ,I ,� �j
Lender's Address 1
I certi{y ihaf I have read Ihis application and state thal Ihe Issvance Fee �•��`i� � �
a6ove information is correct I ogree to mmply with all Caunty Io�asrgorlon Fee �y `�'(� �
nrdlnoncas and Stafo laws reloting to buildinc�consiruction, ioial Fee l�� /.�� � � �
d hereby authori�e represen�atives of this Counry to enier O,,, F
u n ihe above-m ntio_g ned properry for Inspeuion purposes. � , 1
� � k„
�- SEE FEVERSE FOR E%PLANATORV LANGUAGE y�
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