HomeMy WebLinkAbout1122 DIAMOND BAR (8) �
� WORKERS'COMPFNSATION DECLARATION � � � S� ,
�
I hereby offirm,h�f � ha�e a certifimte of�on5enr,a 5e�f -qpp��CATION FOR BUILDING PERMIT �
insore,or a certifimle of Workers'Compenstion Insurpnce,or .
a ce�rfied copy thereof(sec.3eDo,�ab.c.) �OUNTY OF LOS ANGELES BUILDING A SAFETY
Policy No. Company
� Cerrified copy is hereby fur�ished, FOR APPLICANT TO FILL IN gUILUING % / .��
ADDRFSS ( a�
f�C�` Certified copy is filed wiih thc ty buildinq�inspec- guILDING t �/
!d� tian deparimeM. � ADDRESS � �j�/'W[3ti��,�� LOCALITY l �'V
Date {�'�.Applican � CI7Y IP_ NROSS 51. `�•\l�'�� �U�
CERTIFlCATE�OF EXEMPTIO OM WORKERS' O.OF BIUGS. ASSESSOR
� COMPENSATION INSURANCE 517F.OF lOT .NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be complefed if the permif is for one USE ZONE MAP / �/
hUndfed dallbr5($100)Or Ie55.) TRACT BLOCK LO NO. NO. �/�"'��/'� ,�
� C" .M x,,r T L. �,/ �,,,� SPECIAL �
I ceriify fhat in thc performance of ihe work for which th'is �WN�R s �1 w,r�'+� 0:.. '�`F�} CONDI710N5 �
ermit is issued,I shnll not em I DISTRICT GROUP TVPE FIRE PRO ESSED BV
p p y any person in any mqnner qUDRESS -Y� �—�'-� CONST Z �
so as to become su6jecl to Ihe orkers'Compensafion Laws. / � J
n �. �� .� C;7 N � '^L `�
Date A�a t CITV ��^° - ZIP
ARCHIIECT OR TE� r� STATISTICAL CLASSIFICATION APT. DO., �
. NOTICE i0 APPLICANT: If, af er aking ihis Cerrificate of ��� •� ��
Exempiion, you should bec ro subject }o the Workers' - ENGINEER NO. CLA55 NO. DWELL UNITS �,
Compensation provisions of t e Lobor Code,you must forih- �
with comply with such provisions or Ihis permi} shall bP ADDRE55 SEWER MAP s,.
deemed revoked. - ,{�y�:� . �e��^
CONTRACTOR p, �—"��� 8K. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION � �
I hereby affirm ihat I am lir.ensed under provisions of Chppter 9 ADDRE55 �j�—j4 1 � Np � VALl1ATION
(commencing wiih Section 7W0)of�ivlsion 3 of the Buslness and # r uC ��,,� � ..; �j1
Professions Code,and my license is fn full force and effeci. CiTv CIASS �4'1 t+,
'`� "`� 5C]-F�. ' NO.OF 1 NO.OF CHECK
License Nu �r �!� �� Li<.Class , �i� , SILE STORIES l FAMILIES ONF
� � ya-4�2 i � rvtw S
Cont�act S pa�y_� - UESCRIFTION OF WORKw_ yd' f
� I am exempl from the licensing requirements as I am a ~ ADD �
licensed architect or a registered professionol engineer , ALTER � FINAL �� [i .
acting in my professional pacily (Sedion 7051, � � � REPAIR � DATE .
Business and Professions Co J. u5E OF � FINAL 7
� E%ISTING BLDG. ' DEMOL ❑ /
sY" u�c' .�.3
Lic.or Reg.No. a e APPLICANT �+ ,. '9 - 7E�, r
. OWNER-BUILDER D CL�R ION �NK�NT� � ►�v�"� � � �
I hereby affirm that I am exempt om ihe Conlraclor's Llcense t �� � /)
� Law for 7he following reason (Section 7031.5, Business and A�DR[55 �Z—� �"�.+1"`ti-L.�+i.�
Profe55ion5 Code�: PRESENi
❑ BUILDING . .
I, as owner af ihe property, or my employees with ADDRE55
wapes as their sole comnensation.wlll do the wnrk ond
the struciure Is not intended or oftered for sale(Sec�ion tOCALITY _
I044,Business ond Professions Code). MOVING TEt.
� I,os owner of ihe property,am exclusively contracting CUNIHACiOR NO.
with licensed mniraciors M consiruct ihe projecf(Seo- r 9 9 5,8 R -
tion 7044,Business and Professions Code). � ADDRfSS .
REQUII2ED TOT�L SETB�IX FROM E%IST e m o • •
CONSTRUQION LEtJDING AGENCY SfT f1ACK Y/+RD HWY pNOP.LINE WIUTH �- �
� I hereby aHirm rhoi there is a construction Ir,nding agency for �RON7 � . � m�'�2 5.5 Q
ihe pertonnance nf the work for whi�h thls pern�iit is issucd � p.�, . .
(Sec 3097,Civ.C). t� / si�E � '
N•� P.L. 'e o 0 2 5,5 0-c�'i
Lender's Name '
--- a.c reP s Pe.�„��reP ��✓ 1 0,�1 "&.1
Lender's ress {�' �
I certi ihal I have read this applimtion and state that Ihe � Issuance Fer. a + .J G? �
abov Informaf�on is correct.I ogree ta mmply with�II Counfy Invesitgof�o�Fee �
vrd' ances an��5tate lo lating to b�ilding wnsiruction, Toinl Fce ��.�C�*
an hereby authoriz epre4enfatives of ihis Counly to enter �
u n ihe ove-m ntioned property for inspeciion purposes
. �V �"� SEE REVERSE FOR EXPLANATORY LANGUAGE
S� nafure of Appllc nt Agent Da�e �s
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