HomeMy WebLinkAbout1184 DIAMOND BAR BLVD (3) �. WORKERS'COMPENSATION DECIARATION . -� � �� ��� � �- � � -- - �II �
I hereby affirm Ihal I have a certificote of�o�,e�„o self, -. � ��pp��CATIQN� FOR BUILDING PERMIT 's �
� insure,or a certifimte of Workeis'Compenstion ns ronp e�,or j- �
o certified copy iherep—i�pye�.3800,tab.C) 4�LG'ij� , _ . . - COUNTY OF LO$ANGELES BUILDING AND SAPETY
�cyNoy � -�lOmpony � BUILDING /! '
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN nooaess '7 �
� Certified copy is filed with the county b�ilding inspec- BUILDING
' ❑o�department. AD�RE55 �,J LOCALITY �
/� NEAREST
Date�� pplimnt � / Q G7Y �. �� , Ziv � CROSSSL �"
' C RTIFICATE OF EXEMPTION kOM WORKE 5" NO.OF BLDGS. ASSESSOR
� - COMPENSATION I URANCE � SIZE Of LOT . . NOW ON l0T . MAP BOOK PAGE PARCEt
�(ihis sec�ion need not be completed ii the permit is for one use zONe nu+W � 2_/ �
TRACT - BIOCK LOT NO. NO. .�
hundred dollors(SI00)or less.) . � - - � �'
� TEL. SPECIAL . G.
I certif that in the erformance of ihe work for which this OWNER �l '� NO. J cONolilONS � - Q
Y P D�STRICI GROUP TVPE FIRE PROCESSED BY U
permit is issued,I shall not employ ony person in ony manner qDDRE55 ''�'� � CONS� , � y�
so as to become subjetl�o ihe Workers'Compensa�ion Laws. '.
Dote : .. . . .qPPlicant . . . � . CITY � u�^ iP . - � O
STATISTICAI CLASSIFICATION AP. CONDO.
NOTICE�TO APPIICANT: If, aiter making ihis�Cerlificete of � ARCHITECT OR '/ i� � . w
EzempliOn,'y0u 5hould become Subje[t fo fhe WOrkers' ' ENGINEFR � � � "7 QASS NO. �WELL.UNIT$ N
Cempersc!icn prcvi:icns cf thc Lebcr Ced^,yeu mu<i ferih- ` noo�ess � n ��' '� �l sew:a rr�no . ?
with comply with such provisians or Ihis permif sholl be � 1E1. C � - � �
deemed revoked. � . , CONTRACTOR �Y'� N � •� gK. PG, VAIIDATION
" �LICENSED CONTRACTOR$DECLARATION� /' UC, ' � ,
I hereby a(firm that I am licenzed under provisions o1 Chop�er 9 ._.. ADDeE55 � NO. � VAIUATION . �
(commencing wiih Sectfon 7000)o(Division 3 of the Business ond ���, S �
Professions Code,and my license-is in full force ond effeU. CITY � . C1A55 -
�c���,��� . LjZi/ 5�.FT. NO.OF . NO.OF, CHECK � ����
LicenSe Number_�i��lit.Clas� SIZE STORIES FAMI IES ONE . .
1�� S
� ��jl�'/V/. DESCRIFTION OF WORK f . � NEW � . .
COnIrOCtOf- � � Dale 1 ' ADD � . . .
� 1 am ecempt from the �tensing requirements as I om a FINAL �g . - � �
licensed architett or a registered professional engineer _. _ . . .. . ._. .. A�TER . ❑ /a ./ � ,
octing In my prafessianal capatity (Section 7051, REPAIR � �ATE 7
� Business and Professions Code). USE OF . � FINAL � - � �
-- E%1511NG BLDG. � f . DEMOI B � �. . .
LIG.of REg.N0. DatB APFUCANT TEI. � Y - � � - _
� �� - OWNER-BUIIDER DECLARATION � � - -� � (PRtNT) „ i� NO.
I hereby affirm thot I am ezemp�irom the Coniracto/s License � qDDRESS � � /
.Law for the following reoson(Section 7031.5,Business and , . � � .
Proiesslons Code); . '�ESENi ,
❑ . � . . BUILDING . . . . .
I, as owner of Ihe p�operly, or my employees with nDDRE55
� woges os their sole compensoiion,will do ihe wo�k and � �OGnLiTv �
- the strucfure is not Intended or of(ered for sale(Secrion � � �8 9 2� a
7044,Business and Professions Code). MOVING TE�� . . � �
� I,os owner of the property,am exclusively contrac�ing CONTRACTOR N�. ' ' #.�.i •.•�• �
wifh licensed tontrodors ro cons7rucf the projecl(Sec- . qDDRESS -
- tion 7044,Business ond Professions Code). - ��;' '2 J�.5.0 .
REOUIRED iOTAL SETBACK FROM EXIST.
, CONSTRIJCTION IENDING AGENCY SE7 BACK YARp HwY PROP.LINE WIDTH . � •�2�Jr O U
I hereby aHirm that there iz a constroction lending agency for � pROrvi � � �'� • � '
the performance oi the work for which Ihis permit is issued P.L 0 7,•�3�8� '
(Sec.3097,Civ.C.). . . . .. - �SOE -- . - - � � � •
e�.
Lender's Nome _ _, . . . .. (�, • � � -� � � � � �
' � G.C.Fee S . Permi�Fee ` .��+
Lender's Address _, ,. . . � � �
I cerlify Ihal I hove read this opplicotion and slate that the Issuance Fee , ,
obove informotion is mrrect.I ogree to mmply with oll County .. _ Invesega��on fee - �� � � , ' � � "
ordinances and Siate laws reloting io building construction, iaiai Fee ��0 . .
and here6y authorize representaiives of this County lo enler . . . . .. . . - ..
upon th above-meNioned property for inspedion purposes. � � . �
. . � �`A���/ . _. SEE REYERSE FOR EIfPIANATORY IANGUAGE - � .
. . . .. . . ./v. . . .. . ... . . . . . .. _. . . /_.
i�narure of ��- nt or A�ent Do�e
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