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HomeMy WebLinkAbout1164 DIAMOND BAR BLVD , _. � . � � WORKERS'COMPENSATION DECIARATION � �, . . �� �� � � � � I hereby afFirm thot 1 have a tertifitote of�o�5e�,�a,e�f � � . APPLICATION FOR BUILDING PERMIT. .insure,or o certificme of Wo�kers'Compenstion Insuronce,or I� . a certified copy ihe�eaf(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Company � � 6UIlDING � .Certified copy is hereby f�rnished. FOR APPLICANT TO FILL IN ADDRESS � �. aCertified topy is(iled wifh ihe tounty bullding inspet• BUIL�ING / / �1.� 1l Q�, � tion depdrfinent.� ' � �" � ADDRE55 ��V�'l��K/��Y ' ✓[>[-{/ LOCALITY . � ' � � �1 t� �1 �r� NEAREST Date � � -Applicant . . �. aTv.,,l/i'T���O Ziv 7�/�.� CROSS ST. - � CERTIFICATE OF EXEMPTIDN FROM WORKERS' �, � / NO.OF BlDGS. n55e5SOR - COMPENSATION INSURANCE � SIZE OF LOT ��I�7d' NOW ON LOT MAP BOOK 7AGE PARCEL (This seclion need nat be mmpleted ii the permil is for one USE ZONE MAP .``1 hundred dollars($100)or less.� � - . TRACT BLOCK lOT NO. NO. � y � � TEL. �,� SPEGAL O I certiiy�hai in rhe performance of the�work for which this � OWNER �J C��� NO. CONDITIONS ' - ermif is issued,I sholl not em lo an erson in an manner �ISIRiCT GROUP TYPE FIRE PROCESSED BY V p p Y Y P Y f ! . CONSi. ZONE �so as to become subjecl ro the Workers'Compensa�ion Laws. I .4o�RESS �� �U��T A � �-' ' . /�(f��� �'�/,�-, �� J � O Date� ' � � Applicant � . '� CITY Z�P �`�`-'� STATISTICAlCtA551FICATION APT. CON00. (~,� ARCHITECT OR ���� . W NOTICE TO APPLICANT:�,If, offer moking�this Cerlificate of �� ENGwEER � �E� O. � 6��`�'Y CLASSNO. DWEIL UNITS � y Exemplion,-yau should become subject lo the Workers' Ccmpersclicn provi5lCn5 of Ih9 LCbOf COf�2,YOV TU41 IOrlh- FGvnESS SFWER MA� . Z with comply with Suth provisions or this permit shall be TE� . - deemed revoked. � COMRnCTOR- �7 r(.��— � NO. � BK. �PG, . VALIOATION . ' - � 'UCENSED CONTRACTORS DECLARATION � � UC. � � I hereby olfirm that I am licensed�nder provisions oi Chapter 9. ADDRE55 No. vniuAT�oN , . �8 6 9.4 A � (tommentinq with Section 7000)of Division 3 of the Bvsiness and - ���, �(�(� � � Professions Code,and my license is in full force and effeU. CITY . CLASS 3 W�+�OO �� � • •.�� � � Sp.FT.Q? NO OF NO.OF �L'�.— CHECK ' License Number Lit.Closs � SIZE yy�� STORiES iAMNES -L./ ONE �• • • •2 3 � DESCRIPTION OF WORK .TJ/U/D/�./L NEW � S 9� . Contractor � 1 Date . . ;' "O •� 'I+� • � Q 4,� .. � 1 am ezempl from the licensing requiremenfs as I am a �(� 3 ADD- � . . licensed archilect or a regislered professional engineer,_.. , _ .. . .. . AITER � FINAL�; ^ '/ � '• • • � �.�l�c=i � acting in my professionol cdpacity (S2�[�tiCh"-7051, REPAIR � �ATE o� �7� � . �Business and Professions Code). - �'�. ' USE OF � FINAL �7�8'$.� . � � . � . � � " ' � E%ISTING BLDG. , DEMOL By lic.or Reg.No. Date ' nvPUCnNi 7E� q/ '/,'/ � � � ��- � � OWNER-BUILDERDECLARATION - -- " (�RiNT) � � ND.�I/V�`��T �I hereby oifirm�hal I am exempt from ihe Contraaor's Lirense s iq'�/ �.�M � �L���A . - � � ' - -� � ._ Low For 1he following reason(SeUion 7031.5,Business a�d /+DDRE55 fi-J K � Proiessions Code�: . , -. , '�� � ���iSiNi �8 7 5�8 A . O . . . . -.. . B�����NG . � 1, as owner of�the�property, or my employees wilh nODRE55 #;' '.• •23� ' wages as iheir sole compensation,will do the work and ��q�ITY ' � the siracture is not intended or ofiered for sale(Section � -- � � • • •�'�� � 7044,8usiness ond Professions Code). MOViNG TE�� ' CONTRACTOR . NO. � � ' '_ �- I,os owner of the property,om exdusively mntrocting- - �: • • • �3,`�Q c� wilh licensed conira[to�5 t0 CO�sfrucl ihe project(Se[• qpDRE55 — iion 7044,Bosiness and Professions Code). � � � � � _ O 7,� 'J—S� REOUIRE TOTAL$ETBACK FROM EX15T. CONSTRUCTION IEN�ING AGENCY SFT BACK �ARD HWY pROP.LINE WIDTH � � I hereby affirm that there is a construc�ion lending agency for _ peONi � . �s 7�9 A the performance of Ihe work for which ihis permit is issued v.L , � � (Set.3097.Civ.C.I. . . .. . . . .. SiDE.� - . . . . . � . . �• • • •'� � v.i. Lender's Name � ,1 � , - �P�•2�Jr Q � P.C.Fee S ��`[� Permit Fee � Lender's Address - , . � � � !• •z�J.5�� I certify tha�1 hove read this application ond sta�e that ihe . �. �V Issuance Fee � � above iniormation is torreU.I ag�ee ro comply with all Counly _ �n�esrgm�on Fee . � . .. . . . ' � �7'� 3 L�8'� ordinonces and State laws relating ro building mnstruc�ion, To�al Fee �, . � � -and hereby au�horize represemotives of this Counry to enter . . . . . � � upon Ihe obove•meniioned pFoperty for inspection porpose5. . � , � � - SEE REVERSE FOR EXPLANATORY IANGUAGE � � � �t S�gnoWre ol ApPlkon�or Agem , �ote - .... . .. . . . . . . - . . . . . . . _ - . . �''! f1 S ,p . o � �+ <n e N o v� .r cn T� � Gl '^ i 2 _t _.. " _ r; Z --� 0 o n „ -o ; � �o � °c �- \ � 3-• o- >> �o =- ,x-`. : o; �:� f�� m- o 0 0- �,9 0` , r r o 0 I „ � � � � c� a. o �_ � . {nu a. o � i � .� x, �o �c. � o . ,,.p `,o .� o:. vA �r, �. � 3. � ��. �. 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