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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� � Signofure n4/�pplicant or Agen� Doie • \�� m 8 -n cn ��T���__�;_._..__.�.__._..,___..._.,_ro —�n. ^�_+._...,._. 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