HomeMy WebLinkAbout1184 DIAMOND BAR BLVD (4) .. � `\.`_•.•�f"- -%" ' .: . _ ...... .. �� . 1 . . . R . . . . .
� WORKER5'COMPENSATION DECLARATION " -� , � . �
� I hereby affirm that I have a�e�;�f��o�e of�o�5e�,�o=e�f. . APPLICATION FQR� BUILDING PERMIT
� Insure,or a terlificate of Workers'Compenslion Insurance,ar {
a certified copy fhereol(Sec.3800,Lob.C.} f COUNTY OF LOS ANGELES BUfLDING AND SAFETY
Folicy No. Compony �
Certified co is hereb furnlshed. BURDtNG
❑ PY� Y ' � FOR APPLICANT TO FILL IN ADDRESS 1 S � �
� Certified copy is filed wi�h the covmy building iospec- gUILDING �j �
lion deporlmenl. - � ADDRESS O �14�'Jf�/l/� I/ LOCALITY - � -
NEAREST
Dole - Applicont � � UTY ZIP CROSS 5T. -
� CERTIFICAIE OF EXEMPTION FROM WORKERS' � � NO.OF BlDGS. nSSESSOR �
� � ' COMPENSATION INSURANCE � , S�ZE OF LOT NOW ON[OT MAP BOON � PAGE PARCEI
(This section need not be tompleted if the permit is for one uSE ZONE �P. �' i �e1�
�Rundred dotlars(3100)or.less.� � , . 7tt.4Ci etOCK �OT NO. � . -l.� � }
r�. ',l C.3 seean� d
�1 terlify tha�in ihe performance�of Ihe work for w . is ' OWNER � (Ij�O.� ��Ib CONDITIONS �
,pEfmit is i55u ,1 shall nol employ any person in n m0 er DISTRI�T GROUP iYPE f�RE GROCESSED BY (,J
so 03 10 be me su ject to Ihe Work rs' ensotion s. ADORE55 Z► ` CON!ST.}� ZONE ('� �
/ �1 /�� '\O � r.,� yy "\�ti O
�Dote � �AppliCa CI1Y N / ZI7 SIATISTICALCLASS�FICATION � APT. 'CONDO. V .
�NOTICE T APP CA T; If, afle moking ihis nifica�e f � aRCHITE� TEL. � � W
Exemption,�you shouid 6ecome subject ro e Wor rs FNGINEER O. CLn55 NO. � DWEII.UNiTS C.
N
Compensotion piovisions of Ihe Lobor Code,you to�1h. � ADDRESSZ SEL'.'ER YJ+P Z
with comply wifh such provisions or this'permil tholl be TE� � —
deemed revoked: � � gK: pG VALIDATION
' CONTRACTOR ' ' NO.
- .IICENSED CONTRACTORS DECLARATION i�C. _ � '
1 here6y afFirm thm I am licensed under provisions of Chapfer 9 . , ADDRESS � NO.- VALUATION ' � � �
(commencing witb Sectian 7000)of Division 3 ot the 8us�ness ond ' liC. . - ,1 . �',1 9�4 A
Professions Code,ond my license is in full force and etiect. Cliv CLn55 f���\ . �
� S�.FT. NO.OF NO.OF CHECK ' �
�LicenSe Number Lip Class � � 512E ��0 STORIE$ � FAMILIES � ONE � �,•�• � �2 3'
�Conlra[I0� Do1B ' DESCRIPTION OF WORK NEW S�1�(� - . � ���,�'�U a�
W
� I am ezemp�from the licensing requiremenis os I am o R�0 _ •�� �2�$�� ` •
licensed orchi�ect or a registered professional engineer At7ER- FINAL / �y � � .
acfing in my pro{essional capacity (Setlion 7051, .. . . . . REPAIR DATE 7 3/ Q� 0�2 6�$.� .
Business and Professions Code). USE OF FINAL '
� EXISTING BIDG. ' � DEMO[ ❑ B /J�
t.�f}7
�lic,or Reg.No. Da�e APa�iCANt . tei. /�.�� - .
�'-� � OWNER•BUIIDER DECLARATION ' 7�tiNi� � � NO �"w7I7.
1 hereby offirm thot I om exempt irom the Controc�or's license qDDRESS {ZZ �'�"� / '-
law for e following reason(Section 703I.5, Business ond � �6 9�4 a�
°rofe ons Code): . . FeESEtvI �
BUIIDING
I, as owncr of�the property, m my employees with � ADDRE55 ��,� ����23
wages os their sole mmpenso�ion,will do the work ond � �
the sfrocture is not Intended or offered(or sale(Sec�ion ��A��TY � ' �'� .;r�.y y�� �4'� ,
7044,Business and Professions Code). MOViNG � TEL. �
7 CONTRACTOR NO. �-
f,as owner of the property,am excluzively contracting •I' •.� a(1�v�
wi�h ticensed coNractors to mnslruct ihe projecf(Sec- qoDRE55 , �
lion 70d4,Bosinesz and Vrofessions Code). • . � � O Q.� S"$�
REOUIRED. TOTAL SETBAIX FROM 'EXIST. "
CONSTRUCTION LENDING AGENCY. SET enCK YaRD HWV pROP.lME WIDTH - � �• Y` � . ' '
ereby aFf'rrm�hot there is a cortstrvc+'ron lending agency for pgpNi .
performance of the work ior which Ihis permit is issued v L � . � -
:.so9�,r�.e.�. . s�oe �7 9 Q 5 q � ,
P.L _ SI
ler's Name Qt " • • • •.��,
P.C.Fee 5 Q. Perm��Fee d
er's Address I • •6 Z 5 0.
�fy�hat I have read this applicaiion and slate tho�Ihe . , �„ . Issuance Fee� � •��• •6 7.5 0� �
informofion is mrrect.I agree ta tomply with all County investigouon Fee . � . . . .
mces ond State laws relating�o building construciion, � Toral Fee- b � ��
rreby ou�horize r niatives of'ihi:Counry to enier O Jr,P G"8���
�_ �J •e-mentf ne property for inspeclion urposef�s,
� /I�/"/ �� SEE REVERSE FOR E%PIANATORY1lANGUAGE � � -
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