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HomeMy WebLinkAbout1812A 1813A (10) . . __ _ _. _ . ._.._ __... . .... _.. _. � ' WORKERS'COMPENSATION DECIARATION � '�' ���O� � �: �' ' : . � _.. _ . . . _ . . . ._.. ... ...___. � _ . � . . I,hereby afiirm that I have a certificate of�consent to 5e�� APPLICATIO�N FOR�;,BUILDING PERMIT��� insure,or o certificafe of Workers'Compensotion Insuronce, • or o certilied copy thereof(Sec:3800,'La6..'C) . . ..�`... .----�� - --- . _. .�. ._ . ._.. .. COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNaPWCC25382413dYnpany Pac. EmD�r� -- - - � Certified copy is hereby furnished. � , � � � FOR APPLICANT TO FILL IN BU1LD1NG � �,�a `�. �•T-=•-••t� ADORESS � -Certified copy is filed with the covn�y buil � g inspec -- euuDwG — � � � fion depanmenr.�' ' ' ADDRE55 Dare �� npprco�r cirv Diamond Bar -' zir 91765 iocnuTr ' CERTIFICATE OF EXEMP110 OM W KERS' �- --'- � ��- - -���- '�- �NO:OF BlDGS. - - NEARES7___ � _.., _ _ ._ - _ . ._._....__. . __..-_ � COMPENSATION I URANCE� �'� � SiZE OF LO7 NOW ON lOT �O- CRO55 5T. ' ' .� (Thii seUion need nol be completed if Ihe permit is for one � �-�� � ^ ! - � -- - ��-- -- ��' ASSESSOR , - � � �- :� . hundred dollars(5700)or less.) . , . TRAC1� S V BIOCK LOi NO. MAP BOOK � ' � PAGE PARCEL � TF4 U ZpN �P . . . . . .. "_ .._. _ ._. .. . , � _ , �certify thot in the performance of the work for which�his OWNER N �7 V� , r .; �,�. . i} � permit is issued,I shall not employ any penon in ony monner __ q0oRE55 P.�.-�BOX-35� ��- - ��� � �-�-�-� - � �'-oY's� CON�ITION$ T� ��•' � �Q so as to 6ecome subjea io the Workeri Compensation Lows. �,U Daia '� , Appli[onl � , . ,.. . ...".. '___. CITY ._ "_ __...._ . ZIP . . ' ' ' '''_'"'. . _ . ' ' " '._ ... .__,. , :OG O710E TO APPLICANT: If, after rtiaking�thn Cerlificme of ENGMEfR � ' N�' _DISTRICT. GROUP Tvve _ .... . _ -FlaE �o _ __PROCESSEp HY.. ��emplian,�you'should 6ecome subjecf fo'1he Workers' "--���� CONS7. ZONE , V .ompenso�ion provisions of the Lo6or Cade,you must Torth• qpDRESS�.OS�F1 S. Paramount Ave.� Downey . � �`.�' - . 3 ..� _. .—_ 'd with comply wiih such�provisions or �his permif shall be - -- . TEt. ; STATISTICAL ClASS�IFIClATION� ,� / APT. CONDO. ,� deamed revoked. - . .�.�. • . .. ' ,. , , CONtunCtoR Owner NO. '"qA55 NO. VV ' DWEIt.UNIT$.,(�L � � LICENSED CONTRACiORS DECLARATION � ��� - -�--- �- -- �-��- �- - -- - --- ---�-� ��i�,--�- -� - � I hereby affirm lhat I om licensed under provisions of Chopter 9 ADDRE55 h10. , (mmmencing with Seclion 7000)of Division 3 of 1he Business and .. . _ _ �i�. ,. SEwER Ma.P � ' : • � � ..___..__.. _._ ... ._._. .. .... . . Professions Code,and my license'is iqfull force and effecl. aTv CtA55 � '�'-�BK.-��-�� �. �-�'- � � �� �-"-VALIDATION �' � • � _ . . ., , . ... � � . � ' SQ Fi. NO.OF _ _ NO.OF . CHECK .. ' , liCenSeNumber ��5464$ LIc.Class B1 ' S2E � �� STORIES FAMILIES ONE ; . . ' � � � �� � � -• VAlUAT10N. Conirotfor � �� Dote � � DESCRIPfIONOFWORKNEW single family �w- ❑ S 1/�a��rro - ���'1-81.�F ; O ._ . . _ ADD � ,., '___#t•.. • •G� .. I am ezempt under Sec. � wlth BtteChed- 3Ya E.'. q�TER B.BP.C.for rhis�eason �.. . :.: � S � � _I_ �1 8�.b b . . _ _ REPAIR ' " . ' '- ' ,' -"' - Dote: EX ST�ING BLDG. DEMOI ' __ _ _�1�E���,�]C7� ' � Signaf�re -. '._..� � -'- APPUCANT TEL ' FINAL � 0 �... O ER-BUIL OECLARATION PRwT NO. _ _..DATE r.✓/J7 O ,O E+ S b -�hereby affirm ai 1 om exempl�rom Ihe Conlmdor'6li[en3e qDDRE55 FINAt� � / '� `� - Law for�he fo owing�eason(SeUion 7031.5,Business ond � � ..ProfessiansCode):. ..... .. . ........ ...- -�-_ � R .BY. _ __. _ , - '.-` ._. . . ('� BUIIDING _ . . f^\� I, as owner of the property, ar my employees wi�h qooaE55 _f, -� woges as fheir sole compensotion,will do Ihe wark and � ���+� �A� }he sfrutture is nol intended or offered for sala(Section ��`��T� '• � , � � � � � -- � 7044,Business and Prafessions Code):. . _.. . ._. .. MOVING - -_...... ._� . .-- -7EL. . .- --'-.-. ' �._-� _ - ���c�c o •.� �. . . n I,as owner of Ihe property,am exdusively conlracling COMRACTOR NO. . "� . . , �,'- . ' . t}F}( with licensed contraclors lo cansiruci ihe praject(Sec- .� ADDRE55 . ...... . ^�.�..-� �. ..�. ..�. .-..�. ... .��'' e���i O.��. ... tion 7044,6usiness ond Professions Code). . � � '�,, � '�� . ...__ . .. ... REOUIREO" YAR�' -HWY .IOIALSETBACK . __. _...- . '.:_ ... . . _. _. ' ._a c£..� Q.U O V-. -CONSTRUCTION LENDING AGENCY-� sei sneK GROP.LWE wioiH - i 1 hereby affirm Ihat Ihere is a tonstruclion lending agenty for fRONi . � .- �! - - � �the performanta-of�be work for which this permit iz issued ._.. --a.t. �-- . _ . __ . __.. _. .. . .. .___. . : __... . �. ..._. _ ._ .. .... _ __ , . ���"�i0 � (SeC 3097.Civ.C.J. SIDE � . � ; .,.I�l � � ..__ _- ___ _ _ .__. _ . .. _ '_ _ ' . F.L. � . '' - , � Lender'sName ._. ...__ .. ..._._.,- ......_._ _. . �VOR6' - ; . . R drp o S lDM4 Ref.N - � = . . . .. .... .. . . . ... . . - PGFeeS� -' PermrFea I�OS• - - ' - - - .. . .... .-. � Lender's Address � � ' - � � ' I cenify�hot-1 have read�his applimtion and stare Ihat fhe _ _ ._....-"-'. --_ - . i„�„ce Fee . S� - �otitn viC N .._ ,..- - ! --.. _ .�. '"�.� . abova informoNon is mrrect.I agree to mmply with all Counry Invesngano�Fee , . � _ ordinances and S�a laws relat' ro building construuion, .. _ .. .___.. . .____. . Tmol F�r , -- � lDnv�v«m,N- � � � I � � � J ._. ._._..-__.-----_-"-... ond here y oulh ze repres rves of fhis Couniy to enter . upon t abo entioned o eny for inspection p�rposes. I ' ' / . . �7_�.._ Sc.�l�.•._... S._ � .,. _ .--- ._ _ _ 1 -- - - �CL�� SFE REVERSF FOR EXPIANAiORY LANGUAGE �. .� � y.�. -- - _ _ . _ ; �gnai eofAppl�comorAgenr - .. __ _ .Da7e. .. . .. ._ ___.. ____ -_._. , . . / . -_ . . _ _ �! , • PLANS TO APPLICANT ��INSPECiOR'S NOTES �OIVNEI2•DUI[.DF.K DLCLARATI�N , , I hereby affirm Ihal I am ezempl from ihe Coniroctor's Te: . � . R�iurnad ' . � - � ' ' � � , � ' License low�for the iollowing re6son."(Set.'7031:5) '" ' ' -Approved" '� pusinessandPmfessionsCodc:AnyrityorcountywbicG No. Oafe '� No. � Dat�' � -� - -�•� � � � . -. *eguires a f+ern�it to tonttrutl,allcr,inef>ove,demolisl, � � . .�..: �: ' . � . . . ailaa tftor sucG ernit�ro Je a si�ned rtater�ent ".orrch /� ts . r. . ... -.- .',. , . .. ' -� �. . . �.. '..Y =„_. ,j - � +, tGe b� ns ua , I8o ' 1Gat is Jiae ed y�ns nt to tGe proris ns of 1l e Cnn• . . � � �, �,;'. / �-� J. � S (r�; . tractnr'�License�.uw(Cbaffer�f(cornmenting u•itb Sca - - - � ".Irnn 7000f of Dirisron 3 of 1bc l3usiness and Prnfessions I . . . .. ...� ' . �,:..'�� _'._r, CndeJor.J/a0$eisexem/rt lbere�rom:nedlGe6asi.cj rlbe _ .. .. _ .. .. .��._ _ .__ _.__. ._..__. . . . _ . . �' __.___. . . .- -_ .. _ . . ... alfeged,exemp�ion.�An,y riolalrnn of Sedion 703 t.5 by � _.. Requfrod .. . . . ..---. �: .��(.� _.. .---'--� •. .-... anyappficantfornpermitsubjectstbeapplicanlioaaivi! �_._--"A rovols -Dafo R�ceivad.� _ P� or Approv�d, ;1,�' . , •�Jrenafty of no!mnre tbon/ire!unJrrd Jn!lurs(d500J.f: i .� � .�Y�s No . . . ,�' ; � . i.:,• . . ' �� -- -�-� -� -� ��� � - � �-- -' �--�-� � ❑ I,os owner of the properfy,or my employees with Water Certilim�e "�� , �,�. '.� .. � . � _ .. _. . _ . ......- � . .._. -:_� � ,.�'oges as Iheir sole compenzolion,will do ihe wo�k,and --- -- - �the structure is not iMended or otfered for sole(5ec.7044) �-, Heolth�Deportment_--. . _.. . -. .. �� .: ' ._. r: --�- --_ .. ..._ .. .._..�. -�_ _ .. . . . ProJ�ss Ousineis�and ions�Code:Tbe ConOractnr's License � Inw does no!app y to on oumer of property wbo builds � f- Fire DePariment.._. ._ .._ _ ... _ _. ___ -- � - - - .. ... .... . ... .. or imfrooes lbcreon,and u•Go docs sucL u�ork Limself or ' •� - ' � '� � . � . � ; , ; - �- ' ' IHrnugG-,lis.ou�n rnrpluyeet,f�mrided-(baf saoG im- � Grading �. � , provrments�are no! intended or,ofjcred for,su7c.��' � . - � , ,,_ , ._. . . _ � Gou�ever,tl�c builJin,�or improvemrnt is sofJwitbin o�. � �� , . ,�, � . .; . ., ..,.. Geo�giccl�-� . , ' �- - � � . , . � year of conipfceinn, t!c omner-burlder a•ill lave 1Gr � � � ' � � - � burde�of fineing tbat Ge did not builJ nr impm��e fnt __- ___.—__ ._ .__ ._._.___ . ___._ � .. dedestrian Proteclion �.--� �� . � � � tLe/�urpose nf safeJ.'-'- . . . �_ � _: � ... ., �. , , � (Fence)(CanoPY) ; . '.�: . � -- ----�-�-�- ---. -. -.-.- --- -- ...-��. .�. ' ❑ '1,as owner of the property.am exdusively coMr6c- . , , iing'with licensed mnimc�ors to construct the projecf(Sec: "' " � ' " �� `" ---�- 7044)Uusiness and Projessions CoJet Tlic Contractor's �. Special Inspection-�- . - .- -. : . . . - � .- � -�� �-. . . ...���- - -- (Conc.)(Mosanry)(Welding) � � ' � - - � � , + - . , , l.icen+e l.au+docs nnt afply�o an oemer of property u�ho ,_. . .... ` ".. ._._. ....�- .. -. �." . ��.."" -� � �"-builds or iinproaci I!crcon,and wfin contracls for sucG Lot Drainage� �� � �� . . . � � projecta witL a rorttruclor(sJ licenseJ parsuunt to tl�e ,:. . , _ _ .. .-- --._.__ . ..__. ..._ .. , � ' � '-"�Cnnqaclor's I.irense I.airJ. .. .. . .-_- -- . _ . Porking ... . _ . _...... ..._ _ ._...'._ ._._.. . .._ ` ..__. ___.___ _ _. . . . ' . . ❑ I am exempi under$et. ,6.8P.C.for lhis _._ .. t`_ . _ ._ . � „ . �G�4 � K: - r ��i._•.�� ' � - --- reason - , ----- . Da1e - � � Owner � APprovals Date Inspeclor'a ignatun � � � � � � . . .� iNSPECTOR'S NOTES "� Locoiion— , / . . . . � . . . . . . .. . (Setback B Yards) 6 -- - ...... ��. � . . . .�� :; , . . . � �, � . ., . , . Foundalions . ' � _ __ .. ._ _..._. __.'' . ; � .. , .�.....; . . ., , .� , . . . .. Slab �, . .'' / ' � :. --� . . .. . � . .. . . .. i .. Frame . p � . ' � . . ... Energy Insulotion � .��� � �. . � . �.. . . � . .. . �. � . Laih/Drywall— V ..-- - - �-'--- - � -. .._. _.: .__- . .... . . _ . - . Interior �,• --� '----- - i � � � � . Lolh—Exterior �" ���� . . . .' . . . ' . ... ,. _ �.. �. . _._._ _ _ _. ._ ___ .__. - �.� = .. ��" Hovse Num6er— . r ____ ... -. ._ . . .__._. �___.. . . . ,,.__ . .. CorreciBPosted � � _.. . ��-���� - --� - � . . _.-. . � . - � "• � . .. � . _.. Final— . _. . _._--. - ' _ _.. . _ ._._.. _ . . _ __. . . . .._ . . Enler on Front �� '•.i i..� � �� , � �. ..•� .. , � - . ., � .. ' . . .-. , ' � . ._. . ).t . � . _. � - �. . : .. . . . .. - " `,ti,•