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HomeMy WebLinkAbout1184 DIAMOND BAR BLVD (7) .. � `\.`_•.•�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 � � - � �gno��re of Appll�n� Age�� Do�e � �� � � �'� � _ x � a ° � ` ' T 0 0, . I�. ' N =np Q O p O p . -o '.o nv, .� t` o a o `s n . . p ,J;n.� m � �. '� � = 1'�C . O t� �.F- -C7 .y Q� �-,. O 'D :'. 'A G . 7 a �, y. c�'i,a �. :c'o „p �� ��1� R 3 3 a a o r- 6�. ��w �o a m-f+ CZ= o =.,.co 3 6�`, or n`° y t � :'a �a n:o �' m- m� M 'c 7 •,� O O ?'' �. .W d� Q. F'1� 't�� `y � •p � 'p m . ?'• ' r m.0 �a .' �O '� , t- O'� Q°1 II' iI' r-7. p. .i.t.'�_^., r... 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