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'��=
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