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HomeMy WebLinkAbout1122 S DIAMOND BAR BLVD (3) WORKERS'COMPENSAiION DECLARATION � �f I hereby affirm fhaf I have a ceriificple of consent to self : �pp►LI.CATION FOR BUILDING PERMIT LS insuie,or p certificate of Workers'Compensation Insurance, � /"'� or a certifci,eId mpy thereof(Sec 3800,lab.C.) COUNTY OF LOS/►NGELES BUILDING AND SAFETY Policy No r,��'��Comppny Oh�a C��l BUIL�ING � CertiRed copy is hereby fumished. FOR APPLICANT TO FILL IN aooaess I '�'' � Certifiad copy is filed with the county building inspec- BUILDING ''1 [ ry��rnnn ���^ �/ tiondepartment. . qDDRE55 ���G J,L1v1l1�Utl�� J-KIJ �IY� LOU+uTV ���" Date Applicant CITY Ll��.u1 VI L� D�y ZIP ��7� NEAREST CRO55 ST. CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF s�oGS. ASSE550R COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This seclion need nof 6e mmple�ed if the permit is for one USE ZONE M/lP �/���•� hundred dollars($100)or less.) TRACi f�'� BLOCK LOT NO. [ NO. , OWNEft JJ(7,WI'1 �Lr.� ,� NL,-� .31 � �~� CONDITIONS ^"- I rertify that in the performance of the work for which this ? }^] C� ��{ n i_3 �{ DISTRICT GROUP TYPE FIRE PROCESSED 8Y � permii is issued,1 shall not employ any person in any manner ADDRE55 �le'� �J- ��m���x+ 17� �L.'+1vU CO T. ZONE e-' so as to become subject to the Workers'Compens tion Laws. ���� �v � - �: � �/� p/ (�y D«.rr�`td 3r�.r Z�P � Date�Appliconi � Ufil�.� CITY STATISTICALCLASSIFICATION APT. CON O. NOTICE TO APPLICANT: If, afier ma—k g�IhisG� ertificate of ARCHIiEC70R ie�. _5 i.� Exemption, you Shou�d 66[ome su6ja[t to ihB Workers' ENG�NEER NO. CLA55 NO. w�DWELL.UNITS }° Compensotion provisions of fhe Labor Code,you m�st forfh- ADDRESS SEWER MAP . �' with comply wiih such provisions or this permil shall be i,.,, 7EL '1 / �' A.�.A�ve;1ly7�1� NO.���V Q�'(L�� VALIUATION deemed re�oked. CONTNACTOR BK. PG, LICENSED CONTRACTORS DECLARAiION .f g � ���, r I hereby offirm that I om licensed under provisions of Chapter 9 � ADDRE55 1�l�13'(C��� �� ��NO. �I ltl�� VAWATION � (commencing with Seciion 7000)of Division 3 of the Business and ,��$ . ��� /� Professions Code,and my license is in full force an�d+effect. CITY � I�1 U,.(, CLASS �,'9c.J $ �o�-fJ7� ► L n�r �C' i ..,.� 54.fT- NO.OF NO.OF CHECK 'z`J O 3. I R License Nu er ��"�= Lia Class �' SIZE STORIES FAMILIES ONE r�fy�;3(/_ S �-,�P O ¢ u 2 t�i� Contrac a�e �L�~(}i(,f DESCRIPTION OF WORK II��;��Q� NEW � ' �I am xempf under Sec. nP� �d n ADD ❑ i H n 2�`C� AITER � FINAL [ B.&P.C.for this reason � DATE -''J .�'`� " » r o'��,C��� REPAIR Dote: USE OF DEMOL ❑ B NA / � �2��1 '�`H O EXISTINGBLDG. Y _,.._ Signature APPLICANT /l J,� tEL.. ;j r�� OWNER-BUILDER DECLARATION PRINT) ,QC.Adve�hsm L7C� 1 i NO TI�I�f�ll1� �D� ' I hereby affirm ihaf I om exempt from ihe Controctor's License I']t�C Ar'rp �' �.,ft_f�� 1( I��(' � Law for the following reason (Section 7031.5, Business and � ADDRE55 ���J �S WIC lJ U �i Professions Codej: PRESEM � ❑ BUILDING ' '2'v G L',�A I, as owner of fhe property, or my employees wilh ADDRESS wages os Iheir sole compensation,will do the work and - - tha strucfurp ic., ��gr.la.l� ..ipe.�a c�:��!^ ' � inra�iry h w a I .;(S�,^.'don - 7044,Business and Professions Code). MOVING TE�� ���� �.3 G 7 5 � I,os owne�of ihe property,am exdusively contraciing CONTRACTOR ND. wifh licensed coNracfors fo consfruct ihe project(Ser qDDRESS " � °�C'7�4 tion 7044,Business and Professions Code). . � CONSTRUCTION LENDING AGENCY ReqUIRED TOTAL SETBACK FROM exi5i. SET BACK YARD HWY pROP.LINF W�DTH , O 3'� Q—�,,�j I hereby affirm ihat there is o construction lending agency for FRONT . the performance of the work for which this permit is issued P.L. (Sec.3097,Civ.C.�. 51oE P.l. Lender's Name Lendei s Address P.C.Foa 5 �� � Permif Fee .L I certify Ihat I have read this opplication and stote ihot ihe Iss� ce Fae lV^�� . � above information is correct.I agree lo comply with all Counfy Investigation Fee an �� ordinances and Sfate lows reloting fo building construction, 7oral Fee ��' and hereby aulhorize represenfatives of ihis County to eMer upon fhe above-m ntioned property for inspe[tion pu�rpo�se�s. - � Cy{�rILG "��A� �(�(�Z]Re SEE RENERSE FOR EICPLANATORY IANGUAGE Si—gna�lure af pplicant or Agent Da+e �� ��r__. _ . � —_-�..___ T ,--�— �- --r--�; � 'rn 7 40 O __,-�-�� � O 4 ��� � -- � --'-'- � O m ` o ' � �� i Q � � i ... gl ib ; SJ � �� �7 �S �, Q f � O ��O v� � � {I G � :l'G ��W �a i (D � �� § � � G I ��� ! ,. �! ��Q � � i �y�; � :s � i��; � � If o � n I � � � , � a :'o" i j��-•-� ! �G � �� � ; rn i� d � � ' O ��n G i 9 � i Q. 1 ^ � � C' � 1 � 3] � r � 3 ' fl I I. ; 1 3 I� z£ �, -��.4 � - � ;K 7 I �7� : 3 f v-.` .�1� n I 1 � (0',�: � � � �_� ��sY'� � t� O � v n !C I ! ;:� � � cLQ] 1 '�'"'- I G� � � �j � : . � � � e o� 3 �� c� c � v '-� j. ,^ rn i �� 3 ^ � ° � '� � i ! 7 c, m � o. � R ' � OJ - E � " � � ' = � ! 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