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HomeMy WebLinkAbout1180 S DIAMOND BAR (3) WORKERS'COMPENSATION DECLARATION� - ' ��_���W t• �� . . I hereby o„�,m ,har� ha�e a certificate of consenf to 5a�f� -. APPLICp►TION� FOR BUILDI-NG'��-�PERMI�' � � � insure,or a certificate of Workers'Compenslion Insurance,or � � a cert'rfied copy the�eof(sec.3ao0,�ab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PalfcyNo. � Company � . , � Ce�tified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDP.ESS 0� � ��24h��' �� � � Certified copy is filed wilh the tounty building inspec- i BWLDWG / '"� "� /J tion deparimenf. �. A�oRESS // /'�� .:_{.�'� '{ LOCALI7Y l�e�, /.r-�-v� �� !: - �n`•. , NEAREST . Date � Applicant �� CITY. ,' ..�/ro iCJ��/ ZIP CROSS 5T. �,.dUe�'-��-"` � CERTIfICATE OF EXEMPTION FROM WORKERS� NO.OF BLDGS `� ASSESSOR �. COMPENSATION INSURANCE �` SIZE OF LOT- NOW ON LOTII✓a/L�L��' MAP BOOK PAGE PARCEL ,; This section need nof 6e mm lefed if the ermit is for one USE ZONE MAP s s � P P '�1 TRACT BLOIX LOT NO. NO. ,! '�-� �y �e�7 hundred dollars($100)or less.) � ': �� , '7- TEL7�sJ' [L` /D '� SPEQAL � I certify that in the performance of the work for which this �`a' OWNER�/� ' ,y �l�((��' NO. " ��'2��Zp� C�� CONDI710N5 � ' ermit is issoed,�shall nof em lo an erson i an anner /' va�TS DISTkICT GROUP TYPE FIRE P�ED BV � � p P Y Y P . � $ � C 0"' - so as to become su6ject to ih�kers' omp f i Laws. ADDRE55 f� ,Z,Z.-- - %C:/7 /j l✓E..� � �� CONSi�. ZOf�... �� . J�� �+v cnr��/,/liYl`�c. ziN��:L7i`�' �E� � .� <,..i � . Dals�"��^�� Applica ~ ' ' 'Z'� , STATISTICA�CLASSIFICATION API'. CONDO. � , � NOTICE TO APPLICANT: If; aNer moking this Certificate of ARCHITECTOR CPv. 1E�. � 8,! [NGINEER .� � �'-�� CLA55 NO. UWELL UNITS_� 4 � Fzemption, you should become subject fo the Workers' �'y . �}, yI � Iid - Compensa�ion provisions of the Labor Code,you musl torlh- "�+� ADDRFyy ._5�- ,�,�O)`j �L�gX.�/f}� .Crt� SEWER MAP � � with camply with such provisions or this permit shall be�•� . � ' deemed revoked. � � n "" T«� � �y L 7�'�' VALIDATION CONT TOR �X�.�: . � NO. � / ��v7 J�:31 BK. PG, � - LICENSEDCONTRACTORSDECLARATION � - u �,e�a1Sr•4:✓�+��L•Ic.. I herek�y nffirm that I am licensed under provislons of Chop�er 9 .N+�� n ESS� ' (,4/�-, ��'-� (1Z.. NO.�x,Z Z L-� VALUATION � �, (commenUng with Section 7W0)of Divlsion 3 of ihe Buslness and � i��_ /�y-y' - : � Professions Code,and niy Ilcense is in full force and efiect. � ,;� C ' "�if� ��� CLA55 `� �j�✓���e '" -� . , � ' �k �,�i) SW F�'1,� O.OF ) NO.OF CHECK � License Number - Lic.Class SIZE�'7� TOftIES ! FAMILIES DNE �` ��. � Cantractar Date_ ry',�� UESCRIPiION OF WORK NtW � . ❑ . C' , � �D� � � I arn exempt from tho licensing requirernents as I�am a� ^�� � G �- r,�e aireN FINAL � licensed ar<hitecl or a registered professional engineer -� t,} � DATE ,�✓' � acfing in my professional capacity (SeUion 7051, � .�✓fe�FC�i�1N1- — ,,g. .��- ,g�jc, REPAIR � � V � � � Business and Professions Code). USE OF � FlNAL �� � EXISTING BLDG. UEMOL Lic.or Reg.No.___ Dafe . APPLICA " TEL.7i , , P (PRINT CjQY .-It I� NO.. ` '���� � � � OWNER-BUR�ER DECLARATION y� ���. � f� I-hereby affirm that i am examp�4rom the Conirqctor's License �( �� ` �' �. . Law for the foilowiny raoson(Sec�ion 7031.5, 8usiness ond �iy�� AUUKESSj7�7 Z��-�/�Cfff����.L " J[!� /��f� � , � Professlons Code): \>; PRE EN ���,^ ;;� � 1:�.-,�.. '��.� .,`. I.�'��1 ,: �t y BIJILDING ' I 1 I. as owner of ihe properlv, or my employees wilh ADfJRG55 � �i t - wages as thelr sole compensation,will do the work and _ �,�rq....: • f% � �� � � ^L 5 � Ihe siructure is not intended or offered for sole(Section LOCALITY _ � • � 7044,Business and Professions Code). MOVING TE�� �'� ,�};,+ r q !�, �'� I J F. 1�('�'(i �� � I,qs ownar of�he property,am exdusively cont�acting '� CONTRACTOR � N�. {' ,� ��� ' J � + � . with licensed<ontroctors to consiruct the praject(Sec ; �� ;.-, �,f ��i..�.u :..,... ..!.. �' ' �:.U,�:�� . , lion 7044,Business and Professions Codef. , ADDRE55 , ��-� , � REQUIRED TOTAL SETBACK FROM EXISi ' 1(� ' CONSTRUCTION LENDING AGENCY � SET BACK YARD HWY pRpp,�INE WI�TH � y {^� � f L" /'R FS n I hereby qffirm ihot ihere is a construction lending agoncy for FRON7 ' f- 't�i ��t t)a .•1"v 6 �! � � ihe perfortnance oi.ihe work far which ihls perm�d is issued a.�.' Y � n + --�a � � � � .. (Sec.3097,Civ.C.1. SioE . l : `�.�-r,-;� .., 6,. ���G(.{ �� . k''�/ ..,.%,y�-1,. . v.� � ��,�,,�,�;'�,�y�y.���,-s.. Lender's Narne - �"'C��� � 6'- "o� . !�s_i�% e'�'> U.�j. �''ud _ �,` •.;. P.0 Fee S � � PFrmlt F�:a � ),'at�y/N� � Lender's Address - ,/ J 1 I cerhfy that I have read Ihis application and stale ihat Ihe � ,�'���''�'n"' � f)`� �J.�i ,� �f'.� lssua ice Fec . 6"�� ��� "ZL .. 1 rJ e5 . � ahove iniormation Is correct I ogree to comply with all County inves�gonon Fee _ �, � � ' Ei ) s Fl�� ordinances and State laws relating to buildinq mnsir�ction, � lmol Fee � G"f!��� � `r� ��� � ond hereby out o I ,rep sentotivos of ihls County lo enter . Nl��nn/FLj4 a�i fC�/;�(��' �D� �)C;''� � �on e a ov e ion prope.rty for inspecfion p�rposes. ' � �� � �p� . J �,� . � �. � N1 6 n 1 y / 4 r 7'G3 ��S'��= �V�% - ��� %'�—��Z� SEE REVERSE FOR EXPLANATORY LANGUAGE 1�l�� �''+}< <l''4 ��� �'�"�� �p'�"��N '� � i ' S-qnalore o{Applicani or Ayent �� uo�e . �"'�'�c �.;: cS��..d'^• .. . 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