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 ��
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