HomeMy WebLinkAbout1122 DIAMOND BAR BLVD (6) 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
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