HomeMy WebLinkAbout1184 DIAMOND BAR (4) WORKERS'COMPENSATION�ECLARATION . -. .. ..... .. . . .. . . . ,. . . � ��
vl hereby affirm that I have a cenifimte of�o�se�„a=e�f � . . - APPLIC�ATION FOR ,BUILDING PERMIT
insure,or a certificate of Workers'Compenstion Insuron[e,o� _
a certi(ied copy thereof(Sec.3800,lob.C.) . - . . - COUNTY OF LOS ANGELES � � BUILDING AND SAFETY
Policy No. Company
❑ PY Y FOR APPLICANT TO FILL IN ADDRE55 �1 �I � `4
�Cerlified to is hereb furnished.
� Cer�ified copy is filed�wlth the tounty build'ing�inspeo- BuilowG ��
� tion deparimenl. nDDeE55 LOCAUTY � Qf� �
� �I NEAREST ^ �
Dote � � - App�icanl ' UTY ��v� CROSSST. t
� CERTIi1CAlE OF EXEMPiION FROM WORKEHS' � � NO.OF 61DG5. ASSESSOR �
� � � -COMPENSAT�ON INSURANCE � SRE OF LOT NOw ON tOi nv a BOOK PnGE rnRCEI
�(This sec�ion need nol 6e compleled if the permit is for one use zONe �v+P �� .
TRACT BLOfK LOT NO. NO. - ,��� 3 y 5
hundred doilars(5100)ar less.) - � T , SPECiAL }
�� CONDITiONS 0.
��I certiiy thot in Ihe performance of the work for whith ihis '� . OWNER Q �`�Q � . � � 0
permit is issued,I sholl not emplay any person in any manner /� DtSTRICT GROUP TYPE ' fIRE PROCESSED BY
ADDRESS 4J �� CONST. ZONE
so as to become subject ta�he Wo�keri Compensolion Laws. / ,/: (� n '� (�l�.,Oh O
�' `� V r
DOte Appli[a�} � . CITY U Z�P `� S7ATISTICAL CLA551 CATION APT. CONDO. .V
NOTICE TO APPIICANT: If, ofter making this CerlifjEate of- '-�� ARCHITECT OR ��/�J7� � , .
� Ezemption, y0u should betome subje[t fo the Workers' ENGINEER � S . `�'�.7-`K7� ClA55N0. DWELL.UNITS 6.
HY�r� '^
Compensotion provis�ons of ihe Labor Code,you musi forlh- � -- qDDRE55 � � (--= f'(f ...:`.':R h'./P Z
with mmply�wilh such�provisions or this permit shall be � _.
� deemed revoked. � . .. . ... ��' . BK. p�, - � . VALI�ATION
• CONTNACTOR NO.
�.LICENSED CONTRACTORS DECLARATION LIC.,� �
I hereby oifirm thoi I am licensed under provisions of Chopter 9 A�DRESS - _ NO.� VAWATION
(commencing with Section 7000)of Division 3 of the Business and LiC. Q �p pp A g b Q 2 A
Professiont Code,ond my license is in foll force ond e(feU. . CITV CLP.55 �S � �.] �
� SQ.FT. NO.Of NO.OF CHECK "
LiCenSeNumber �iC.CIoSi 512E STORIES FAMI�IE$ ONE - #,�'�'•-•23
CoMractar - Dole DESCRIPTION OF WORK N� ❑ ,E ' � . �I,• •� �b O
� I om exempl from the licensing reqvirements as I am a nDD � _
licensed orchi�eU or a registered professionol angineer . . . . . � ALTFR � �FINAL � � � �6��
oUing .in my professional capacity (Section 7051, REPAIR � DATE � O�O2"S�
Business ond Professions Code). , USE OF - DEMOL �FINAL� ' �
E%ISTING BLDG. � I � ❑ BY
Lit.Or RBg.N0. . .. Da�e APPIICANT TEI. . - ..
� ' - OWNER-BUILDER DECLARATION ' ' " (PRINTI . NO. - .
I here6y affirm that I am exempl fram�he Contrattor'i litense . . . . . �
Law for the following reasan(Seclion 7031.5,Bosiness and A�DkE55� � -� - - � •
ProFessions Code): � � - :aESEni �
D . � . BUILDING � . - � � , �
I, as owner of Ihe properly, or my employees with aDD2E55 �
woges as their sole compensation,will do the work ond . . .�
- the strvctore is no�iniended or ofTered for sale(Seaion�'� �«ALiTY� -� - � - ����� ---- Q �
7044,8usiness and Professions Code). MOVING TEI. . � .
� - � I,as owner of fhe property,am exduslvely coniroctinq GONTRACTOR� NO. � - � � � �
with lirensed conirvclors to construN 1he project(Set- � qDbRE55 � � �
. � Iion 7044,9usiness ond Frofessions Code). -- � - �� � � � �
- REOUIREO TOTAL SETBACK FROM EXIST. �� . . .
CONSTRUCTION LENDING AGENCY SEi B/.CK YAR� HWY PROP.LINE WI�TH
� I hereby affirm thollhere is a construction lending agency ior FNONI
Ihe perfarmonce of Ihe work for which this permit is issued P.t.
(Sec.3097,Civ.C.�. . ... _ . . si�e - � - � - �
P.L. •
Lender's Name \ . . �
Lendei s Address P.C.Fee S ��•b� Permi�Fee � � -
I certify ihot I hove read this oppiitotion and sta�e that the � issoance Fee � �
� above information is corteu.I ogree io comply wifh aIi Caunty � _ i„�esegouoo fee � � � . � � -� � �
ordinances ond S�ole laws rela�ing to 6uilding conslruction, To�al Fee �
ond hereby authorize represenlalives of Ihis Counly lo enter , : . - - � � .
upon Ihe bove-menlioned�roperly for inspedion porpose5. � . �
_/ ���� . SEE REVERSE FOR EXPLANATORY LANGUAGE . . �
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