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HomeMy WebLinkAbout1164 DIAMOND BAR BLVD (3) � , ��WORKER$'COMPENSATION DECLARATION ' . � : insure orat�ertifica�eofWorkese1Compenarionlnurantesolr ! �-� APPLICATION FOR BUILDING PERMIT- . a certiiied cop ihereof(Sec.3800,/La+b.C.1 COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo�/Y�B�'-sa Company�.(� ����� � / ��,^Cerrified topy is hereby(ornished. FOR APPLICANT TO FILL IN qDORE55 N L ^Q Ir N�Certified copy is filed with the county building inspec- BUILDING Lt_ I �� / /,/ �—L tion deparfinenf. /� ADDRE55 '� 4�D I,74� I(/p� LOfi1UTY N'10ne'{ I,7C✓ � Date��fL_Applicant �✓�'��l R `a CiTY ra� � r � ZiP 1�� CROSSSST. �� .. .. . ' , CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR ' � COMPENSATION INSURANCE SIZE OF l0T NOW ON LOT MAP BOOK -� PAGE PARCEt (This secrion need not ba complered if�he permit is for one � � u5E ZONE �.P � •�/�3S/�✓ _ TRAC7 BIOCK tOi NO. NO. hundred dollars(5�00)or less,) . � } . . . .. . .. ✓e` iEl. ��J SPEGAL _ O I certify that in the�performonce of the work for which this . OWNER Q r�l .JG � NO. � CONDITIONS " ` �permit is issued,I shvll not employ ony person in any manner , Q � a ' OISIRICT GROUP TY7E FIRE PROCESSED BY V ADDRE55 � �'�1�� ���N . �ONST. ZONE G so as ro betome subject to ihe Workers'Compensalion Laws.' �p PQ . ' • ��LP�LJ � �ate Appliconl QTY ' a��'��oJ� Z�P STqTISTICAt CIASSIFlCAiION APT. CONDO. V �NOTICE TO APPUCANT: If, afrer moking this Certifimte of � ARCHi7ECT OR tE�. � �l/7 . a � Ezemplion, you sho�ld betome subjetf to Ihe Workers' ENGiNEER NO. CIA55 NO. �"� DWELL.UNITS N � Compensalion provis�ons�of�he Labor Code,you must forth- .-" � Z wilh comply wilh Svch provisions or Ihis permif 5holl ba ACCRESS SEWER MAP . deemed revoked. � - . . ��l/)�}d Sl^Qp('� NO. 7G?� VAIIUATION � CONTRACTOR BK. PG, � . _ ' �- LICENSED CONTRACTORS DECLARATION -A� tIC. - �� � , I hereby offirm 1ha11 om licensed under provisions oF Chapter 9 ADDRE55 6 W�'fi No.a�a33� VA UATION � (mmmencing with Section 7000)of Division 3 of the Business ond ^,-v LIC. C[{JY ��`s • �9•1�7.b A . - Professions Code,and my license is in full force and eifect CITV W� ' �1A55 � . , �+ ! Sq.FT. NO.OF NO.OF CHECK �.• •.���'2 3 �iCenSB Nulnber���`��a liC.C�a55��� $IZE STORIE$ FAMILIES ONE ' � r /�� C tl►RaTP'!.. � NEW 5 . . '.I��.•� Q�l O Cantrattot�v��7�4'4�0 Dole ✓�,.._ DESCRIPTION OF WORK . � . . . aI 0m ezempt from the licensing req�irements as I om a ��l �f ��' e I�.�.� �^ ADD •.�,�� Q(1 Q� � litensed archiletl or a registered pro(essional engineer . . . ALTER -� fINAI _ � ,,• otting in my professional� copacily (Sec�ion 7051, ' REPA�R � OATE � .�8,Q�7�8� 06siness and Professions Code�• u5e OF yy� ^y. � �" FXISTING BLDG. "I V s�v` S�ie DEMOL ❑ B NA� Lic.O�Reg.N0. ' Date� APPLICANT /� � TEL p,/}� � Y - � � - - OWNER-BUILDER DECLARATION . � IPRiNT)`QJIn C NO. !`(7C3 , I hereby affirm that I am ecempt from the Contractar i License ]�s �t�',�y ��a�q . . ' - . Law ior rhe following reaeon(SeUion 7031.5,Business and A�DRESS v 1 •� . � � . Professians Code�: , � FaeSirvi � - � ❑ BUILDING ' ' : 1, as owner of the property, or my employees with nD�RE55 woges as iheir sole compensation,wili do�he work ond . ' the svucture is not in�ended or oFiered for sale(Section . ��AtiTY - - -- . � � � � 7044,Business and Professions Code). MOVING � TEL . � - ❑ CONTRACTOR � NO. - � ' ��,as owner of the property,am exdusively tomracting �p 4 Q.9 A wilh licensed contraclors ro construcl the project(Sec- qDDRE55 � � ' � Iion 7044,Business and Professlons Code). , � �#�,�,• • •� REOl11RE0 TOTAL SETBACK FROM E%IST. ' ' CONSTRUCTION LENDING AGENCY � SEl BnCK YARD �HWY PROP.IINE WIDTIi ��� �2��.5 O ��� I hereby oHirm Ihal lhere is�o mnstruction lending'agenry for fwONl � . the performonce.of ihe work iar which Ihis pe�mit is iszued P.L •'• •2�,t 5 0� -�Sec.3097.Civ.C.). - - -� � SIDE � - �� . . . . . P.L. Lender's Nome '1 ���f) � � �Q 2$�$� Lender's Address P.0 Fee 5 /!/• Tv Permu Fee 13• � - i[ertify thot I hove reod this application and stale Ihat ihe Iss�once Fee �/J•�/" . ` above iniormafion is correct.I agree to comply with all Caunty Invesr�ga+ion Pee � � ardinances ond State lows reloting�o building ionstruttion, , _ �/ �a , � � and her by aul iz r es ntafives of Ihis Counfy to enter ' Tofal Fee ,. i S opon- bov e - d roperty for in5petlion purposes. . - � i �Q � QC7 O � SEE REYERSE FOR EXPLANATORY LANGUAGE � ' - � ' S��oiure oh pplicom or Age�� Dole � � �s . _ �� o , �U � -�' � O 1 . " r, CR "*+fJ m A � Q Q ` . . , 't7 ,p (1'6 � t]- O 0- � �' . 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