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HomeMy WebLinkAbout1164 DIAMOND BAR BLVD (11) WORKERS'COMPENSATION DECLARATION � • i insvreboraatcertifka'teofWorkes''�omPe�sa,o�=��5�,a��e`�� i� � �. �� �- -APPLICATION FOR �BUILDING- PERMIT���=�--- or a certifled copy thereaf(Sec.3800,Lab.C.) � � GOUNTY OF LOS ANGELES � BUILDING AND SAFETY Policy No. Company BunoiNG �� � Certified mpy is hereby fornished. , FOR APPLICANT TO FILL IN — nooaess f��� °���-^�'+l �� �1�[/I� Cartified copy is iiled with the coonly building inspec- BURDinIG /'Q� ��f }�-�tio�deparfineM. . AD�RESS - tOCAIITY Vt � ,,.�}� NEAREST Dafe Applitont _ CITY ry� ZIP CRO55 ST. �� � � CERTIFICATE OF EXEMPiION FROM WORKERS' - � NO.OF BtDGS. ASSESSOR � � COMPENSATION INSURANCE � SIZE OF tOT NOYJ ON LOT MAP BOOK PAGE PARCEL -(This section need not be completed if the permit is for one USE ZONE /�P ��,..- �� hundred dollars(5100)or less.) TRACT e�OCK LOT NO. _ ' NO. I Te� _„ sa�an� a I cerlify ihat in the peiformance of the work for which thit OWNER � NO. CONDITIONS _1 �DISTRICT GROUP 7YPE FIRE PRp�E55ED BY O permit is iss�ed,I shafl nof employ any person in any manner � 'ADDRESS �V. GONST. ZONE V so as ro become subjetl to the Workeri Compensation Laws. ,./". � � � V Dote APPlicant � . CITY � L ZIP. . ... . . . STATISTICAL ClA$SIFICAI N . APT. CON , .O NOTICE TO APPLICANi: If, afier making ihis Certifitate of ARCHiTECT R,��+? TEI. ... U Exemption, you should become s�bjecf to the Workeri ENGINFER NO. CU155 NO.�DWEII.UNI75 � Cempensalion provisions oi the lobor Code,yOV must forfh- _ ADDRE55 - - SEWER MAP � � ith comply wiih such provisions ar this permit shall be TE� s� 1 � ? deemed re�oked. CONTRACTOR � NO. �` .7� �� ��gK• �� � - VALIDATION UCENSED CONTRACTORS DECLARATION LIC. . I hCreby affirm thol I om litensed under provisions of Chopter 9 .ADDRE55 "r NO.�� y qTION- (commenccnq with Section 7000)oT Division 3 of the 6osiness and �" ' ���' CY � � ` � Prafessivns Code,and my license is in full forte and e{fect Ott i ClASS f7 ' +=� ./J �f� 5�.FT. NO.OF NO.OF CHEIX , � . . � license Num6er llc.Class�% L : SIZE STORIES FAMIlIES ONE J '/ f g303�.t A � � � DESCRIOTION OF WORK N� ,�-�y - # Contraclor pote L � . ADD -� � � .��� � �2 3 I❑I am ezempt u der Sec.� � qt�g � FINAL � f •,�2�r O , B.BP.C,for this reason - - - � - � � REPAIR DATE �/�� _ , � • �'�251Q�c�s � USE OF• O FINAL ome: exisnnrc eio�. . oenno�.❑ B ,0 S 0 2—$4 r Signature � APPIICANT TEL . OWNER-BUIIDER DECIARATION vRINT ' NO. • ' � . I hereby affirm thaf I am exempt from the Contrattor's License � qo�aESS ' � (� ,���- � � law for the following reason(Settlon 7D31.5, 8usiness and � �'��" � ���- ' � �-ProfessionsCode): � peE5eN7 � � �-� � � ..❑ BURDnvG . . . . _ . __... . . , I, as owner of the property, or my employees with - qDDeE55 wages as thair sole compensa�ion,will do the work ond � � � ._ tha structure is nat IMended ar oifered far sale(Secfion . LOCntITY , ._ _ , . . . . . . . � 7044,Busi�ess and Professions Code). MOVING TEL. � � I,os owner of the properly,am ex[lUsively tontratting CONTRAttOR N0. __ with licensed con�rotlon�o constrocl the projett(Seo- a�RE� �3 0���9 A � tion 7044,Bos�ness ond Profess�ons Coda). . . . � , � RE�UIRE� TOTRLSETBAIXFROM EXIST. #������������ �. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.LINE W�DTH ' ' � � I hereby affirm Ihat�here is a construclion lending ogency for _ FRONi - - � � ► • - � - I��"�3 Q 7 5 - �iha performance of the work for whtch this permit is issued 7.�. ' � � � � - � �Sec.3097,Civ.C.J. SIOE • _ •• �3 b 7 5� _ ' �!M� P.t. -_ _._ . .. _. landai s Nome ��7/VT � �S�$�$[! • . ... ._. _ . __ 7 ....._ . .. ' . _.. . P.C.Fee E ��� Permit Fee , p{ � lender's Address �� . I certify ihat I have read this applicotion and stale that the � � Issuonce Fae O- � v � . ' above iniormation is rrect.I agrea to tomply with all CovnN Inves��ga�ion Fee '_ ordinante and S�a ows relating to boilding conslruc�ion, - � � - �-- Towl Fee - jG. 7.5��� � � � ��� ' dnd her y avthor' reprcseNatives of thie County to enter � .-upan e a ve ioned proparry for inspectlon porposes. �� - � -� � � � � � � -- � � � ��� ��- � �� �� �� SEE REVERSE FOR EXPUNATORY UINGUAGE . _ _ _ _ . _ _ ,. _ . . . . . . . � �a�ure of Appii<ont or Age�� Dare � . � �� � \i ._,; '" - 0, � � � � _Q- ��'� ..,. � C �, ..O �,: `, � '1 '. u, �+W a 4' O S (t � '� � � �-c o, o� �p o a v '�' m �o ! 1 0 -r+. '°.� iP ° v - � '° i a . �` :o",: ^ o c� �,', 3 p ° � t � `� � i � � � N O W �` �i� .�C1 . ,.? �N �'� ',, �i � �' °� ". � '�" .+ � o �n � � ` 2 0 0 ;� 3� 6 n- �� 9 ,' � ° �o -�Oc n ' � " o ` �'� O 0 ? 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