HomeMy WebLinkAbout1164 DIAMOND BAR BLVD (17) 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 ? "� � �� / O 4°\ .Q[ '� `' � .�'�'.�� 3 ' , 1 O � O
v ,
�� Q ry ,t*� l�.[ 7�: � ;;i u' p w V � ��L N
�� Rn2 ^ o o .� � ��. a �. ,� i o' r
° a � "c
o p � r
� -0 3 ` ' � M ° - t'
o c .� w a ' � ' s'
� ;° � `' " o ..o.: ?i
G
a, O . _ ..� G .` O
p O ,
+4 _
� 4 ,'
1 � � �. � w+ '96
O � � 9
.Y
� t y , l" � . '� O . �
0 , / � _ �p � P�
O �
.�. \ � . C�p,
w� ��
tf; ' %� �
O . . . .�'. J, .
� � i �
p ' , �` i:`. ,-+. , , ,✓ r ` t.
- J /,. '�' '"� L-
'r, I�, � %
'• .. � �, , r
�� �i . ; �
t. , ✓ /'� ' i1 r/ ' "�
i i . ,.t•. y�
. , •'`J , `• ,' ~,.. ��'J fT1 �
, .. � `. i �t . �
-, 1 1� � �r,. v'
�7 �r1` � r:.`�' l„�•%. . �,
'. ! ��, / �' � . �.=
''�,,' ��, •� ✓ -: /
'' , ,"J ,i !�,. f•. %
��,' ,1: .`, 'f. � i�. ./ �� =�. /!�� .
' ' , � ' � ;i' �' !� � J^ �:•
. :'�,�/ � J � � j .j� .i :
�� � , y� .
, '�
�,�' � 1
� � . `� __ "� �
/.
.. ' ,, �'.. . '. . :�. � �f. . .. � � .
. i �,•'• �, . ._ . . . .
, �•,, ' ' i , � . � r�
�. . ' . C O �a n �
w. :t C�' ~'A ,�,.� [�.
. , ' � G P C O � �p f! F'''Y 4` l9
3 'S L�'�' `S �a a �
^' � N p �C P o"`��.1 N-a'"''r...'�.� p r`G a
� . ' ry` r� '��po =1 �•� N•= � v��� pC"�� �W¢.�n.`l.
� � f. C� P e- C � � C..N � ~'Y. � ii ii"�l, '1 �'1, `'S
' �tM'.o� � r-�' '�' =a°� � a ^ '��O `'s• = ��.r �`^�+" � o �� �
. h"'s� � ^ A� �.,. C G_-� C O N � N � �'. `-'� O '�".-�• Cv
. . �� � Y a„�..bi f, ' C-a ^.�..':.x y.n " � W �O ,4„w.�»A d`° G.'t ^ C .,�n S p ✓
. , ' O� O ' O ^ N�"��+ ��',� O�C �.� y+ N w ��' N 7 = 1 � tn� N'��T n '�t " Oy p ' '�
. . �s o c, a �,�.�o � y ^ `° a o A�� o°`� °� k �� « �' � � 0 3��.,
� / �� . . O K K ...� ^ W O `O^O��.ca K, �b � � d"' r � �� :i�P`O`d..i�.("� 0 M
' r 3 �-�� c_� �, � .p� 's„� " °'e N•oo ? ��'1�, cs: = '. .°. �z.. 'cx ,�,�
.,: ' O ^' O n �, CL� n� 3 '3� � ' C � 7 � fl � » C w"'��� _ %; � � Ci
x �.c. H .,. - � Hav - � o � a3 n
� n �' N r L+.� O � -.. Jo ...^J .�i N D� .�..C Q io L"-� w C �,•+� 9
� . " ' 3 � O Q � t.:.�' � " G'� Cl 4-7 O '� �.�. �..-1 ea "�..C '„ ... Z r
v w '"y ,
t n 3 � �� tS0�. „�� �.�v k G �O p Q `o �i •^�=-.�^yu w N.:�Y � ,..�
o � �. � F � �N o o N �.� . . ,� o r
• � ....^t�.,�,"�,,�^ �a ' o,��„ c a o o.'< � " : o -e Q r �•;{ 0 3 A,
� . 2 c�+� � =' �'.e�:�v c'� o a o'' ..�ry? �'-^`°,,,,,n �� �.v. �'o c ? s .�S '
' ro `�.�, ^. 5. m t"Y � o`�'+ �,v.,�' es £_° �w �",v:.� N +�.p^;= � � a p '
�
. n1 � �' �C..3 �� O ��^ " �..�..Si.n p � � O'� C�c c�a C..� M G..H'� '� t� ?�.
4 Q � 0.w
�.."• . . � . � _e�i �:� p„N � � C.^h A.� f: '� N O � 4 A 21 Q'�10`�.«� 'a Y, J Q
.. SJ � �� �.,,� �. (9 'n vi� �.-,�, "t ^ Q?.� N �„�TG `1 �' �� f. 4'. .T � � �.
� ' . ' N u'O � '��i �� � G.r.y tG � b O � O L,��+'W y� �C' i O
=•� 2 ��+-'�•-'��� � • :, �:.��-.,��'� .u+£� �o ."'.o�, �'h;,'�^''.� �N
t-� � - � -. t�t� p _ ��b n ��� s"F,.'� ��G C"n 7�'w p n �n�,y��"� �''�"C
. u' f . a� ���'o co .�'e. � s��..s-¢ �.b.�eoo �- :...�.�m '"
'� : , ' � F a n Y � n q � �� ` � n�� .. �
l �O ,�,,,`-w Y �t � � �o O �3 O �io.i
l. '/ V . n� y�{ ��� '�w�.3`�'� t
/� _ . . ' � w F..O d n � ca n
� � . ' , O R _..-� [�
� . . ' . , 5 `,��p v;
�'� �) ',, ' 1 �
f.f
L ,. �