Loading...
HomeMy WebLinkAbout1180 S DIAMOND BAR BLVD (7) WORKERS'COMPENSATION DECLARATION . � � �I I hereby aff��m fha, � have a certifimte of�a�=e�,�0 5e�f APPL�ICATION F4R� BUILDI�NG PERMIT s ins�re,or a certificate of Workers'Compenstion Insurance,ar � o certified copy thereof(Sec.3600,La C.) � COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.�'�Company��'^"-L'C BUILDING � Certified copy is he�eby furnished. FOR APPLICANT TO FILL IN ADDRESS � � '� � (� Certified mpy is filed with fhe county building inspec- BUILDING �-� ''J� �.,�q/ �pI��� � Y� tio de arfinent. ; ADDRE55 �/adt,�_�bK LOCALITY ` h�+�Q/L. NEAREST Date�, Applimnt �� ' ����. CITY �IP CNUSS SL .�'��� ERT FICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGa a55e55oe COMPENSATION INSURANCE ` SIZE OF LOT NOW ON lOT MAP BOOK PAGE PARCEL (This section need no�be completed if ihe permit is for one USe ZONE nnnP '�/_�'��j� hundred dollars(S�Oo�or less.) �� TRqcr eioa �or No. No. . ,,. � TEL �1�� SPECIAL p, 1 certify Ihat in ihe performance of the work for which this OWNF.R COND�T�ONS 'b,'� permit is issued,I shall nof empioy uny person in pny mpnner iJ DISTRICT GROUP TYPE FIRE PR CESSED BY y� so as to bemme su6ject to the Workers'Compensation Lqws. � �+DDNF55' .j�-t9 a� ' `yy ��ST- ,.� ���J (� c.}� � GCl ��'S . (' Dote Applicant '� CITY ' � /�3Gi{/LIP ST/�TISTICAL CLASSIFIC TIpN APT. CONDO. {,J � ARCHITFCT OR TF.L. y,y NOTICE TO APPLICANT: If, ofter making Ihis Certificole of I. ENGWEF.R NO. CLA55 NO. ���� DWELL UNIfS_ � ��• Exemption, you should bemme subjed to the Workcrs' s01 Compensation pwvisions of ihe Labor Code,you musf forth- ADDRESS SEWER MAP x, ith mmp�y w'th such provisions or this permit shall be TE� �• deemed revoked. J N�.76 �' gK- p�. VALIDATION ' CONTRACTOR . LICENSED CONTRACTORS DECLARATION �1 �j� v - . I hereby nitirrn ihat I om li<aised under provislons of Chapter 9 ;,_ ADDRESS v S� No. (� q VALUATION (commencing with Se<tion 7000)of Division 3 of ihe Business and `� +�� tIC. Professions Code,and my license is in full force and effect. .°� QtY �/l.(J, CLA55 C-� � $ . � �/ � �I ({ Y�� '.' SC-t.FT_ NO.OF NO.OF _HECK Li[ense Numher �% � Lic Cluss� �'� SIZE STUkIES FAMII IES ONE . . F ���/�.� DESCIiIPTION OF WORK NFW �I Contractor �' ' ��`�Uate�� ❑ �7 5 8.7 A ❑ �.y ADU 1 om exempt from the licensing requi�em Ms s I am a � licensed archileci or a registered professional engineer ALTER � FINAL � iy� #e s-e�0 2�j acting in my professional capacity (Sedion 7051, a REPAIR � DATE � Business and Professions Code). � USE OF � FINAL �-m °2��� � ;� E%ISTING OLDG. DEMOL Lic.ar Reg.No. Date � APPLICANT ` tEt. BY •-��.e�°�i.Q�J cxi � � OWNER-BUI�DER DECLARATION � (PRwi� � '��' �;�� O. � �' - . F I here6y affirm that I am exempt{rom�he Contractor's Li.ense i r�+ / ( �' ��,Ci 7�8 1 � Law ior the followi��g reason(Secticn 7D31.5, 8usiness end ADDRE55 �U 7 4'� , L�G,. . Professions Code): � •� PRESEN ^ '' Bl11LDING . ul I. as owner of the oroperty, or my employees wirh aDOREss wages as Iheir sole compensation,will do the work and � , fhe structure is not intended or offered for sale(Section � i.00AUTv - r 7 5£�8 A � 7044,B�siness ond Professions Code). ' MOVING �Ft. ❑ CONTRACTOR NO. I,os owner of ihe property,am exclusively coniracting ''�' o e�o c e.� wilh licensed ronlractors to wnstruct the project(Sec- � qoDRE55 tion 7044,8usiness and Professlons Code). � W�m 4 3 5 p P.FQUIRED TOTAL SETBAIX FROM EXIST. '� CONSTRUCTION LENUING AGENCY 'SET BACK YARD HWY pgOP.I.INE WIDT4{ I hereby affirm that fhere is n conslruction lending a9ency for FRON7 . n c 4 3.5 0� the performance of the work for which ihis pennit is Issued P.I. �se�.so9�,c�.c.�: s�ue 0 5,0 7�8 1 r�.i. Lender's Name � y/� /.�{ � lender's Address _. P.C.Fec S do��v Parmii Fee ,J• � . I certify that I have read ihis opplication and sfote that the Issounce Fee �J�� - obove information is correct.I agree to comply with all County � I�vesuyanon F�c ., Y[ � � ordlnan<es and State laws relaYing to building consirucifon, lotnl Fee T i��-%'� and here6y authonie representaiives of thls County to entcr � �po e a6ove-mentioned properry for�ins ecfion purposes. . . ��'�„`'. ��,,,�?.yt.�� �-- ,� / //��/��' SEE REVERSE FOR EXPLANATORV IANGUAGE � __�__r_F '�C`s Signoi�re of'Aapllcnni or F+ge��i DcnP / . � l_—.� � � � a o1 C � ^�_ � � a � '.:...q._ i m y�- �.. yrn� n= r r! sn -n :n 5 -i-� {� �� � � ^Cn � �v � � � � -s j S S;f'..._ � .. . !..�s.� �t g t ]q p7 ❑ O i 7 ' O _.. L: O W � ?} ! Pj p � �� o � f � � � ��; � � � 9y ,� � � , --y, � ± � �N 4� � S��!� Q-' Q f� �� � � -s n � iL a � ! i2 � I 1 O I n�+ , � ��Oi �. �� � Q.. Q OI� 3 .:�., �- �Q �n r :4 � � � � � � � i I �� z fe �G 7c'�� �. 3 � - Q � ;i ! O � T 4"c � ` � o Q, i I � a I Q �3 n� S � ! � � ro. I az ; � i �� �3 � �� g C N �� � 'a ^ut� � "O I 1 I � _ 1 o a- o' — -G ¢ ro :� ' � � '� 1 � 3 .-i^e `� � Ll � 'Y O n � O I !N � '� � � ��- ro :u � i.� _ � -� Q o �! ip�i � � � � �. o� ., � i - . .� � �c,n � � t36 m � �i � I i � I� - T� � � � � ., � ; �._.!_ 3 ____L_�� .____.,�.-__�. " m i � � � ' o- i �� � -a i � �. ' I i� � �.___J..__.. I e � � 1 1 � �'e -- �._..__. _1.�r�� I.�_........�. � , o � � � i {i � � {�� � � � � ; _�_._�,_. � � � � , �,� �� , �,�-I � � ; �._ J.� g. � � �� � I ' � ; ' 4 � ; � ; � Cf' � ��� 1 �� 1 `` �' n i � �g i °.� °�. � I � � � � �1 0 � - - --- ' -_._.�.�t�. �� , .w i � 1 � q �� � } � I �i � ; �, � ` � ; � � �-� � , I � � � °: s � s� � � � � � � ti � � I :� � ` ; n i ( � i fi � ; �; sp ,� � � I � S � �,� � � � � � � � � �_�._ 1____� _ __ . �_ _�_.1_�� . ____�_�_�__� __� __ __ :__ __��___�..,�_._ .� , , , � . � � Y : � � � � i � I � - 1 � ' { , , > > , � � ; M � � , _ � � , � J � ' � � i � � � I � I � ' �� � f � � � �� � # I � ! ° i ` �: I � � ; I . � , � � ! � � I � � , � � � � . ' � ! � � � � j i O �'rr c-;�v -• V �� S.'`r ; a ''+.b T f ':r F � n M.^? :;,u ' � 53 r"� � p _' O C .�, n�A� r W :q � � .�^+ v � A � (R� r�� ��L �LY.�Y � a`e. C' �4` � (B S I ' :_. ^ " .. - � � � � �i n �'b ?L� --=` '°o � .:'k � �� � � — ,,,,�� ��� �,�� y.Y' � � ' � h •4 �S- 1? C~''�4 R t�a b � H n f� : ��,� y p�^w�.�.`S'u' q �� � y.��'� a�^ � a b ° u�` y b o � m 3' `" � � " a o r n a'z�' �. � ° a; � � ra ... e� � o K � a ' a._. m o � �, a �.`,, � ? x `r��^t "�h w � a`G'' A � `T�' „`N � � ti'� u � S�*`^ .� '�` -*�? I fB �i(� O � (D � ~ •�S� �' '��T�'S' �y J � .�. `�i ,td b(j i^y O 4 ,`^„ p O � T7 3 � � �, A n.� a � .:� m':a�o o � o � " •�,�y�` � �:� � �J � a x o .,", a R.n o m�"a � 0.s � a �+� . m � a � n �• ' _ `0 3- � c � � «,R 3 ` � �•� V x� p j � o w� }� N.�� � � �� w s Q � ' "�7 �- g •m' o ^o-n� �t S� o' � �-, I . s � � A h �h�O M °A` V.�q �'°C` � S� �y 2� q A �'2 b,W S A�''!Y y y O Q � i -�a u, �c ��� o a a� �°� �� c�2 1D�6 M a a. o Q � �s ».^ n 3 r•, i � a - a � o � x „ � o � � `•,'er n � o o` � I-" `A O °� N m r�s �'y �� R'� °� o'�a"a��'� j '�� ": � � � `"C cv' ��x y � `< " " C �'v �� ti1�'� � fi" ����S o � �,�cfl � C�1 � � .. no � � � �' ey � Qa„m, xy � p � -���.� `" -oC: O � � � o � Q �� '� � �,A � o YY"" o � :: o�' ^�y.� � m t^ ; ' m � �s �. 3 ��h�„` �� 7�-£• w m'�+a s� o " � ._::. a o�' B6a l:.^ m n.x •� ���'�1 q O =3 �p �� y C A p � �^ p � � � � '° y � i,K �v 0.`�"b �, ° ��c �t�' n �" m ;;" �'o ? � � i 3 ' � � �,,� �N � � oA.« � � a " ° r� °�.p�,� � :�i ? o � 5'e�I i � � _� y �� o o � V � .� y � � i � so R � vP ���,,o, ""c � n'�U � � -o � '�A'o n. �° m M � a"'tS oc o A' 7 � i n ..^"M �' � o o. � SS A n � ° �"^ � m �° o':"�"�'ao m^ `° �`� `�3 � O O � � n Y ? W � �tC�t�O ��1'4�w Q A �O �y+ v S� p ` �Q f � � � N S�� �•°e � Q a S�� ���o�h y'e', � �� p v.�A y n � � h yr��� co u o ��. � +o � ^s � a's