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HomeMy WebLinkAbout1122 DIAMOND BAR BLVD (2) WORKERS'COMPENSATION DECLARATION � � �� � I hereby pffirm ,ha� � ha��a�e,f;,��a,e of conseni to self qpp��CATION F�R� BUOLD��NG PERMIT insure,or o certificate of Workers'Compenslion Insurance,or a cenified copy thereof�Sec.3800,Lab,C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company � - � � Certified mpy is hereby fumished. FOR APPLICANT TO FILL IN 611����N�' \`� ��y��` ADDRESS � Ceriified copy is filed with Ihe<ounty 6uilding inspec- �W�DING �j Z � �f�.MbN� r,r p �V./ ' tion department. ADDRESS � D��'•' iocaury y-A N NEAREST �,` Date Applicanl ' ❑Tv �r�,�/8 �7IP CNOSS ST. CERTIFICATF.OF EXEMPTION FROM WORKERS' NO.OF BLDGS. aS5ES50R - COMPENSATION INSURANCE 517F OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one �gACI' 6LOCK � LOi N USF 7_ONE NOP �1� �� hundred dollars(SI00)or less.) . �,. �+�d+.!/' � ,t.�( T[L. /" SPECIAL � OWN[R ,1�1��'�\ ���•Hui� No. e•� coNoirioNs � I certify thaf in ihe performance of ihe work for which ihis ��,r DISTKICT GROUP TYPE FIRE PROCESSEO BY $� permit is issued,I shall not ernploy any person in any manner � A �,,/�,��+ so as to hecome subject to ihe Workers'Compensafion Laws. ADUI2E55 �rfsri.. V/G� . CONST. ZONE C� � ary LA'w f�i3• ziP '�i 7 \C9 C�j SSG :5.TL- �C'(�oJ\o� � Dofe ' Applicant STATISTICAL CLASSIFICATION APT. CONDO. 5,� NO710E TO APPLICANT: If, atter making Ihis Ceriificate of ARCHIiECT OR TEL. � � Exemption, you should become subjed to ihe Workers' ENGMEER NO. CLA55 NO. 1 DWELL.UNITS ya Compensation provisions of the La6or Code,you must forth- ADURE55 with mmply with such provisions or this permit shall be SEWER MAf� ��i„�� � deemed revoked. NQ l�pN�'}} .CONTRACTOR [3K. PG, VALW I� LICENSED CONTRACTORS DECLARATION- I hereby utlirm thal i arn licensed under provisions of Chapier 9 AD�RESS N�7. - #'}e m e o�7`j VALUATION (commenciny with Section 7000)of Division 3 of�he Business�nd - LIC. Professions Code,and my license is in f��ll force ond effect CItY " Cb.A55 � 'i v e � O,Q(J . Sq.FT. NO.OF NO.OF, CHECK � License Number Lic.Class SILE STORIES FAMILI�S ONE a,s v '� ���}�; S � DESCRIPTION OF WORK NEW �Q'� .Jr��.� Cantractor �ate� a1 � I om exempt from ihe licensing requirements as I am a � r��� �d� �IV� A�� ❑ licensed archi�ect or o registered professional engineer ,[' �..y� ♦�f ALTER � FINAL acting in my professional capacify (Section 7051, rb J ,'` ��� ~' REPAIR � DATE � Business and Professions Code). USE OF � EXISTING BLDG. ���� DEMOL � FINAL By Lic:or Reg.No. _Do}e APPLICANT � �j��y��TEL. /f„• � ' OWNER-BUIL�ER�ECLARATION (PRINT) /\ J•"+� R N _y� I hereby affirm ihaf I am exempf from ihe Coniractor's License /p,�j c� /� ��J � L�w for Ihe following reason(Section 7031.5, Business and ADDRESS(A�FI ���/[�-jJ /Q•/l� � Professions Code): P ENT � I,a s owner of fhe y, Y P Y BUILDING prppert or m em lo ees wilh ADDRCSS n w ges as iheir sole compensntion,will do ihe work and ',�d.i-�� iiie sirucrure is not intended or offeretl tor sqle(Section LGCA�iiY /�r, - � 7044,Business and Professions Code). MOVMG TEL � � I,os owner of the property,am exdusively conlractiny cONiRACIOu Np, ri�`� � �, rr Q with licensed conirpctors to tonsiruU the projeci(Sec- AODRE55 tion 7044,Business and Professions Codej. ��,y REQUIRED TOTNL SETBACK fROM FXISI. ' � CONSTRUCTION I.FNDING AGENCY Shi 6ACK YARD HWY pgOP.LINE WIDTH I hereby affirm that there is a construc�ion lending agency for FROn�T the pertonnance of�he work for which this permit is issued p� (Sec 3097,Civ.C.�. SIDE I'.L. Lendei s Narnc - (� Lender's Address � P.C.Fee 5 \� .\S� Perm�i Fee I certify thot I hove read Ihis applimfion and stnte that the Issu ce Fee above informotion is torrett.I agree to mmply with oll County vestigation Fee - ordinances and Sta�e laws relating to building construction, �otal fee . and hereby authorize representatives of�hls County to enter upon the above-meniioned properiy for inspe<tion purposes. � � SEEREVERSEFOREXPLANATORVLANGUAGE � Siynafure ol Appl��cant or Agenl Dote ' �cjy ' ___..._.� ___. . . ;�� _._.. r � ...�..F�.__ � _.._..�._�_._. .__ _.__ g .� .....�...��,...___....;...._..._.v._._ _,,;;..._.a ' ��°o o ° �' � m � I � = c�o�f � e � o yn-o � ��c�° � C:� 999 C) _n ' x � t. � —'�'—.,._�I �'_@ F � ;p�� � :1- �� � 3 € �- � � �Cr{:�I� � F t � � ^ �� � f o... � y �� fl ! � � �_.�._ii-,.�. �' O � t�ro � J G� � � ; � �Q O ;'v { � i o � �� �z � � � � 'i S - � I� � Z x `�� I - i ° ^�� Y ,aas � i" � e ^ f° o i � ro � �� m` o z ! c o �Q' � ! � � � �� �� a -a � _ a t i d � - � � ' �+ ! � °� ;,� �i. � o i � 3 - ° � ° j� fl ° � ss 1 ° � ° ° � �0 3 3 e � '�i I ro ', 4 �;• k _ 7 Ti �� � S C .a : c I ' � � � � �_ � � ? ` � � � �� � � ( � i � � v� � � N � � � � . .i_�,.dr.._.,.....,.�....,.� Q � t� a I � _.�_�` � � � , � � , � i; � �'I �_ _.._.L__s �I�_ '--- '__,;�I_ ; � � � � ;- � � �9 � � ' i��� � � , � �� �3� � � � � ��.. � � � _ ____�._° . - --�s--- � I � � � �� �� � ,�..._i___ ai—� a _ — —�� . � � � � � ' I � � , � ' � ' ° I i ;�I � � � � � � I � � ; � � } � � � � � ! � � � -�----�-- - --�--,__�-�--�- 1 I d =� , q � � r � I . � � � , �, , C � � � i w' I � � I I �I � � -_�--�r—�_. = I � � ��: ,, y � � i � ; � I � �f, .�:� �I i �' i � ° y ,. a I � � I �� �9 � � � i �. ! `� G i3 I I � � ii � � � � � � � � i r � � � �� � �.. , � , � _ � : � _� . } _. _�_�_ �__. _^._�_—_.�_._.�I .__�:�_._�__ -.-- y .__�_ __�__a_----�--���- �---__,_.� � _._._.,_.: � � , . � � �..;;� i � � � � � � :� .� � �: ; � ; . . f � I . � � I � � �- = ...:� I � ; . 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