HomeMy WebLinkAbout1122 DIAMOND BAR _ ,
�.
WORKERS'COMPENSATION DECLARATION � �
� he,eey aff��m that I have a «�f�f��afe of�o�5e�,fo se�f APPLICATION FOI� BUILDING PERMIT ��
insure,or a certificate of Workers'Compenstion Ins�rance,or '. � �
a cerrified mpy thereof(Sec.3800,Lab.C.) I COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
PolicyNo. � Company
❑ BUILDMG
Ce�tified copy�s hcreby fumished. FOR APPLICANT TO FILL IN /�" AD�RESS �� v�
� Certified copy is filed with the county building inspec- � gUIL�iNG ���') q ���M'CN� Q�R-�V� �OCAI.ITY {..�++-��,.,.
tion departmeni. ADoaess �,� ,sirr
TA � /� NEAREST
��Date Applimnt CiTY J 1 r�MDN ,$�7'lC �ZI7 CROSS ST. k�0� �
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSf550R .
COMPENSATION INSURANCE SIGE OF LOT _ NOW ON LOT MAP 600K PAGE PARCEL
(This section need not be completed if ihe permit is for one USE ZONE MAP `� �
- hundred dollars($100)or less.) fRACI BI.00K LO Nn. � W,,.
T . �'� SPECIAL ',v,o
I certify that in ihe performance of the work for which this nv'/�ER • � ���} _ �A�Cf/ NO. •3 CONDiTIONS �
ermit is issued,I shall nol em lo an erson in on anner .f �+ DISTRICT GRUUP IYPE FIRF PROCESSED BY #,,).
P P Y Y P Y^� �I CONSi. ZONE
so as to bemme subject to the Workers'Compensation Laws. AUDRE55 �j s�40 � � Gt✓ � C�g
G✓L/�e �T�• a...
��TY ��P q r r t� � M.c� .c� �
Date Applimnt .STA715TICAI CLAS ICA710N •� APT. CONDO.
NOTICE TO APPLICANT: If, nfter making this Certificate of � /+RCHITECT OR TEL. �.�t,t
Exemption, yoV 5hould beCCme 5ubjeCt fo ihe Workers' tNGINFER NO. CLA55 NO. DWELI..UNITS u'
Compensation provisions of ihe Labor Code,you must forth- qppHE55 SEWER MAP , �
iih wmply with such provisions or this permit shall be
deemed re��ked. . con�Ten�roa- V�� �� Na 4 eK. ac, VALIDATION
IICENSED CONTRACTORS DECLARATION ���.
I hereby atflrm that I am licensed under provisions of Chapter 9 nDDRE55�v g W° � NO. VALUAQT,IOf�
�mmmencing with Sedion 7(%�)of Dlvlsion 3 of Ihe Business and G�L�(�ai..w. 3 CLA55 S q(}{/�s4 4 =9��.2{�,
Professions Code,and rny license is in full force ond effect. CITY A — G/�r�'e•�+ 63 . ..
Sq.fT. NO.OF NO-OF CHECK
LicenseNumber Lic.Class SIIE STORIF.S FAMII.IfS ONE � �w e a.a�J� .
s
oEscRiPnoN oF woeK NEw '1 �+ � 1 3,6 0
Controclor pote_ �1 /�� �
� I om exem t from fhe licensin e uirernenfs as 1 am� ~�N �`Lv M�N�r'—� � ADD � o,� � T ,
P 9� q 1 3.5C��
- litensed architect or a regisiered professional engineer C�R�. �� �}/ � AITFR � F��`1A�
octing in my professional capacity (Section 7051, "� � �^V RFPAIR � DATE O�,.� 5��,,�
Business and Profess'ions CodeJ. USE OF ��f�}j�, �1���/�-fR' DEMOL � FINAL
EXISTINGBLDG. r��Lj B
Lic.or Reg.No. _Date APPLICANf p�� iFl. y ,
OWNER-HU�LDER DECLARATtON (PRINT)V° STryK� y� �
I hereby affirm ihat I am exemp�from ihe Contractor's License /'
Law for the following reason(Section 7031.5, Business and ADDRE55� S�' `•7�� {���'� � � t /t1'�J G'�.�L�` �/�,�j��
Profes•sionsCode)� � PR6EN . �"�J
� � BUILDING '
n , -- -__-- -----... -- - --�- --- :.� .��..�� .__.
U �, .,>�.���e� �� ���� N�.,N�,��, ,., ,,,y �,,,N,,,Y��-., ..,,,, ..��R��� �
wages as tfieir sole mmpensa�ion,wi II do the wark and
Ihe slruclure is not intended or offered for sale(Sectian LOCALiTY
7D44,8usiness and Professions Code). MOVING � TEI_
� I,ns owner of Ihe property,am exclusively contractiny CONTRACTOR NCI. � �
with licensed cantractors to construct the project(Sec- qpDRE55
� tion 7044,Business and Pro(esslons Code). -
CONSTRUCTION LENDING AGENCI' RfCZl11RED yARO HWY TOTAI SETBACK FROM EXIST:
SET BACK PROP.LINE WI�iH
I hereby affirm ihat ihere is a construction lendiny ngency for pRONi �
the perforrnonce of Ihe work for which ihis permlt is issued P.L �
(Sec.3097,Civ.C.). SIDE -
P.L.
Londcr's Name � �
' P.C.Fee S �. Permii Fen \�
lender's Address__ _..
I certify ihat I hcve read thls application and state that the . Issi co Fee _
� above inforrnat�ron is mrred.I agree to comply with nll County . Inveviga��ion Fee
ordinnnces and State laws rel�ting to buildinq construction, iotnl Fee �
ond hereby outhorize representntivex of Ihis County to enter -.
upon ihe above-menGoned property for inspection p�rposes. �
- SEE REVERSE FOH EXPLANATORY LANGUAGE
S�ignature uF Applicanl or A{�eni Doie , �s
..--�'�$��
R
� r�.Q � l
� J
,_ ��.�"'�-^'�� ',
i
;C � � � �3� :� � � `�
'��� A � � � �
�
� �r e C'�"NV ,': � ro 9 r � , � ��� �.•Y � � � ��, 4
� � ' ��7�. � o.:��• � ^ � � � �
„ ....- �` � ¢� � 4�. ii 4'�
` ....F t �� �� � 4 {� � Q ,� �� � � . R�
._• �, �O � �`3 # n 3 � .n 3 . �+ �� � fD � . P'
N O .(D� + �' � � ,j v. .�..y �O . .�.« •i 18� °R. �`,,
� - ! m � \ 4 1 � '6a•' 8+ �u, tU Q� �� y � � �
� q? q n 6 , a Q j�,�'�} , '� .,7'-* �n � .3
.-��.s, (1'r S� .?e. (p _ '� '� , o � �'t � :b 43
.+a.n,e,...+� 4M�• p 7 f�.-"'; � � �° � t �C ? � ��"'�� � `� � �,�'
� ay Q y �l� � N�� � �,�. 5�1 �
Rl0 ...,�;D O1 t1'f��SD.C� � � 9 '� i� , (% � � �: �, �! � �
��`, ``�y� ra �°o a� �Q i � �,, � � ,, �� ,a i '. . �, � ��„s
� , � �, , ; � � � _ � � y�---'�"� � � . �
, i� °�o� " � � � , �.-- � � � tA--�' �J� �'� � �� ^� ti,�� �: �
�.� j ,.-a � 't ,� ��
� � � �•� , � � .
,..-�_`''...--� �y ; i
, � �� � � � , � ,�
�c� � � � � . , -�
� �`„�`��e "� ���� `1 � `'� a� � � F'
t ^a
t \ "''� t 1 � � ' � '� �£° � v
----�i ; �j � t i �t �� t �
''� ` ` y � [` j 0 � G+
,,.�-�-�"' -"'� � i ���., , . 9 1 � �q.' � . .
� ` � o� ��:.'f.�f`,���.,�'.
� 1� �� � �. ` �
' i ;� , � \
t } � � F � ,
� � �.� � �: E:
� � �
� � —t .
� , .
� � � � � �� � �, 9
; � 1 � �
� . , :�A _ �
'; �° �
s � �, �
� t � � �` .s` � ��
, � ,. . ,
i `s'
� - _ ° �
_ � � � �_ ��
, ��,, � .:�:. ,
� 1 44 t .
: � ` `: �, , -, ' .4 ':. :x: �.'� , Z
, , °�� �.. � ��.� y ;
, " i-, � �j
l �� ��. j�' ?��, y��s � <, ` \
1 � � � - �:" .�, � .�, ' ' � ! ,
� ; , i � 1
� ` .�_� � ! �� 1 � .
, �
}.. � � t
� �
1 � ; � � � �. �.,n � � ��
, � ^ 5
� A t C��p M�' �� �' N�
� ' t � �ru�� e A..� o ""'Aq'�a.N � p S O '
� P Y �P
� 4� � i y~ �..'tg ,., ��� � ¢ �.��....+b'�.e"�.,p G m ��"g A � P Q �
. G L.�y Q O �p �� '� -° 'n z�.e � ��N"��� S�"�' ^i�
� -.a" � :_ µE �� sn.wcQ - o �� a"� � w N'� �3 ;d
� �..�a o� '�, � �,�� � - � � � -�,� � ��,� :��,.�:,. �
��y g+. " A� "��� � � Y? �O v� pr .G. N �eY in 9 � .�i p S C.d
O O '<�*. � 1L � e`i�^+�..� m G' ..� � N � Q M. �'�•"e.p r'��W �S+'.,�s� h N 5 Q �.
C} .'u ��p N•- � "V� q n F$' K� p,R.N ' f, �O, C � .. C�,b, g,,,' E,' b ' C� ,,,✓�
� g � �,� � N h �x;"" �'.e`a '^ „' ,.� �, 5 � "'g' � � 't � a C
, � � � � rt °. ';"r �° �'`3 � W ¢ o m�� D �c� -°s� � o� .� r'� �� 03 ;-:1
1` � � � � a � � «.� m � S O O� �.`° � p'C8�A�N Oh' � t� `�co e'� �S'o� �4' � r'�
� '^�w�' � e� 7 w �} R .'$ � w'1'S' `4 .�. Q � p
� � 3 ,�"� J" � � a.'� = °"� � x� ma S' a �'z " ° A "' r -s rt -�s'". � W ;�
2 ��p �� a.o °"— ^"`� � :i�a.� tS c-tDN o��p� "� ' a '"Y o�i a��
i� n � a� �
. ` . 'O � � `.:..`" .,�q 3 W .r�'��' � ¢'�'d t + �a^a.� Q N a q O -�t �+`b"' .'4 '.� c4n O "� �
� � c ,-+�c �,�.�+,¢ '� � ax a.� a� �' oo � � ��; o� p"�^ � o � 'A
� y A P �w"a n'O p £,+�"�-t c� G''4 � � x" 7 3 � �v' 4` i� .^�i 9 rt
� � � 4 m �� °'?'^ �,-p �.� ° �`- ' '� S� o A'm`'*p y � �'^ h'� ?� � "�
t � es+ :?._ ..o �? ^�s � � : �'.. '.w?�...m tc 4 ea � �.� � ,��,.a�r�'� d � U, O
"'q c/� +�.� xi n � -'� �7� � v �":` °� �4 �{ z-°.�. w`"'..S 23 '� � t`�u A e� � Q p�
1 , � ��1 n � o � c� o 0 2 ���� F..y` � l,
Y !"A.� G7� fl �e..��-.,�.n 9 � m � a A.� o p A.
<; � � c,.�e� 's`eY* N n S er+�3a�..*.'^ m iL �.1
� �.. `�" �' �� a.w 3 X.� .,� �.,� ,w� sa q s�� '� .,a P '� � <.P crc � o n
� ti � � tO � k a."= � `O c r. m rn � � o�..,�,�;��'. c � w`a
'� � � � '� .� Y°�� �n. "` � �'���`�'�.h_n o� o g �°'��^ m t'����$�u+
' 1, � *J � '�y �`� v `� � ��• � � q «: ,.,�� N �`L.4v� ? �
, - `n � 'q� � � 3 �o .e '+ �a �� :.m `�m t� ¢ �' `::°,"'..•`� `°
� � ko 4' �'� �m e+ � e�^� X `.° V,�-+.,..� n p.�
� K ro ��-..=t ^i .n.. � Q O � C.,� H"co�
i '('� ��,G. e4ai�, O��'"_'^''�s
+ p �,, 9 m
, , p 4.� ��'n l� °+c
5 � �
� � N
, �
` �