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HomeMy WebLinkAbout1184 DIAMOND BAR (8) 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 . . � �� na�ure of Appl�coni Agen� Do�e �s > > o o ° Q � � �^ o N o �° ��'-' �^ �,� Gl G� �! x � - Z � �o � c �- �- m o o � m � ° �° _o m.� .�.a c� p o �o o: , o 0 p I n fD � � � m p � p. 0 O �;� '� y� ^. nf_�N � a � i� � � � X 1 O � ,0 �p �''Q �� `c7 � � 7 p �T .� • , T �Z � � • ic-� ,o { :�'7 '1�..s ic o n- m � p fl. � . 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