HomeMy WebLinkAbout1180 S DIAMOND BAR BLVD (21) 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 �
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