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HomeMy WebLinkAbout1790A 1791A (10) _ . _._ — -.-- _._ _ _ __.__ _ .._. " Wl7RKER5'COMPENSATIONDECLARAT�ON ':-. �..-. .• ',.i - '" , i .. ..... _._._. .. . .. __ ,;' ., ._._ ._..... _ ... 4 hereby af��.m ,�o;���o�e a.certifico�e of�o�se�„o 5e�f ���—� �����-APPLICATION �FOR���BU�ILDI G���PERMIT -�-�� �� •.insure,or o cartif care of Workers'Gompeniation Insurante, or a ceitified copy thereof(Sec.3800;lob.C.).. ..' . . . --- - . .__ . . . . . ._. , . • : COUNTY OF LOS ANGELES BUIIDING AND SAFETY � roi��YNP.WCC253824�0mpany Pac. Emplgyers .-.-- �� ' � Cerrfed mpy is hereby furnished.� FOR APPLICANT TO FI�L IN BUILDING � O ���� ADDRE55 � Certified topy is filed with ihe c� nty buil 'ng' ec � BURD�NG tion deparlmenl.� ADDRE55 � � �� � ' .. . . . __.. _.. _ ... .. .__ _"' ' . . oa�e ��Z� pplitant � citv Diamond Bar ziP 91765 �ocr,uTv " CER7IFICATE OF EXEMPT FROM WORK 5'. � " "� � - - '� ���---- ����'--NO.OF BLDGS. - -�- r�aeeST . :_. . ._. ._ ..__ _.__. ._ __ _. .. " � '� "COMPENSATIO NSURANCE � � SIZE oF LOT . NOw ON LOT -�- CROSS St. , �This,ietlion need not be co pleted if the permit is for one ���-� � - Jy^- - -�� � � � � - �- � -� ASSESSOR . '-` - � -� .�,-, .hundred dollors(4100)or less.) , .. TRAR � l V BLOCK LOT NO. Mp,p BpOK ' PAGE PARCEI - owNerd�1:J: Brock & Sons - n�i�29-8170 u zop�e enna ���3� Ycenify that in the performance of�he work(or,which this �,�rb No. � '' 'r � permit is issued,I shall not employ any person in any mdnner pooae55 P.�.-�BOX�3SO -- �- SPECiAL - ---- - -- - � � - --- ,0. . ..... ..�. . ...�-�-� - ' � CONDI710NS so as to become w6jeci to Ihe Warkers'Compensmion lows. ' -� ,V . . Appliconf . ."• .. --�--- Giv .. .. .._... _ . ZIP ..---._' - -. - ... . ,� �� 1�� 'O APPUCANT: If, aftet making'thrs�Certifico�e of ARCYIITECfOQ TEt. DISTRICT. . GROUP TYPE ._ .�.FIRE PROCESSEDBY Q ' yov should 6ecome subject�to-Ihe Workers' -�- - FNGINEER L.C.. �`�8�OfS & l�SSQGb.sE72.-8177 . �� Z� � �e liion provisions af�he Labor Code,you mus�forih• qooaess1OS41 S. Paramount Ave. Downe 4D �� ��. � � - � � G�. i�P Y� P .Permn sfiall be- : ... . � . . � _ . .. .. Z 7� 1 .with Suth rOViSions Or th(5 �� �- TEI. STATISTICAL CIASSIFIGATION � AFT. CONDp.' pt.CfJ revoke[I. .. '• . �� -� � CONTRACTOR OWR2I' NO. ' � �� LICENSEDCONTRAQORSDECLARATION � � - - - � --�---- -- - - - - - �- -- -- -�i��. - ----- - - an55N0. � �� �Oweii.UNiTS � I !-hereby affirm thot I am litensed under provisions of Chppter 9 AODRESS NO. (tommencing with Secfion 7000)of Division 3 of ihe Bosiness ond __ _ .���. _ , ��R�P ' - - � � .___ " .___". ' __'._____. _ ___.- . �..�:r � Ct. CITV ClASS ' ' .. ' . . " . �-- � "�-- -- ... VAUDATION ofessions Code,�and my license is in full farce ond e fe , .� . � . . . . ��..� 50.FT.''_ ' NO.OF ._ .NO.Of CHECK BK. FG. n �ICense Number�SGC1�F� �Lit.CIa53 R� ' SIZE � STORIES � FAMILIES ONE ., .� ',^-�,'���O r1 cno�va�ro� ome _ , --- with 1attachedNearale.le family �EB 1 � - ,; -—t•� • • •2 3 - VA UATION � /�aZ�ui� I am exempt under Sea . . . . . - � � - -� --1 °f'�7����' � B.BP.C.for�his re son � �.�.. .. � ... _. � f-- �� � � � REPAIR. ...._. _ . .." . "__' ." . ^ �V f: I��L.�c=i ' .__ . . _ - � USEOF - �-� ;_ . .-. . . ...�. � _ . . - .. ... . Dale� EXISTING BLDG. N�A DEMOL - . . .• - ,•� � �.:. �1 0�'�-�b- + '�-Signature �" - . .-._. . aPvuCnM te �, FINAL � NER-BUII DECLARATION . PRiM T'I.,I. BI`OCIC Sa SOi1S N�Z9-a17O ...DATE - �2�'� - ---- --- ----�- -1 hereby aff r fhat I am exempt from Ihe Contractor i Litense qpDRE55P.O. BO7C 350 Brea CA 92.f721 ow far� ollowing reason(Secrion 7091.5.Business and FINA � ': ,.. : .._ ' ' �"�: . - . �..aessfo Code): ......._. _ ._.....,._._'." . . _.. R . sY _ _. ` �.�•I, os owner of the ro er� euuoiNc �1 7 9.,1 A p p y, or my employees with ADDRE55 wages as their sole mmpensation,will do the work and ' � -� . ' - , o - the sfructore is not iMended or oifered for sole(Sec�ion ��`��TY , , " , ' ��,� ° � � � . - � - -7044,Business and Professions Code).� �- ' "-- MOvinlG ------�' � -TEi.-- - - - � - � - -; �� �r I,as owner of Ihe property,am eaclusively contracling CON7RAC70R NO. . ��.�� , 1 � '�1 9.0 6 . -with licensed contractors to tonstruci the project(Seo- .._..- . _.__._._ ..__._ ._. .._._._ .. _ . __: . _ ., ..._ . � .. . ..`j � T.., �ian 704E,Business ond Professions Code). ADDRE55 � , �, , <' o�I Q Q�` .REOUIRE�. .IOTAL SEiBACK - -' -- CONSTRUCTION LENDING AGENCY�-� ---- ��- - Sei BnCK YARD HwY GROF.UNE WioiH � � • , ' G�!',G�'F�6 ' , i hereby affirm that�here is e canstruc�ion lending agenty(or FROM ' � � the pehormance of�he wark far which�his permi�is iasued �� - v.L . .- _.-. -_._.__ .. . .- • . . .�. - � .._ . �. - - __..--._� - .__._ . .. _... (Sec 3097,Civ.C.). � SIOE - � � "�'� � � : m ' " _ __". ' __". .. . ._ P.L. ' . . � . . � leppler's Name Np,¢�. ,5'C� IDMA ReL M � $ __. _. _ _ __ . ,,77 P.�.�ee: 6B - — Pe,m,�Fee DB _ - � - _ _ - Lender i Address Ill,� � , i - �.• . '�. � . I mrtify that 1 have read ihis application and state thot Ihe !' - - . . - -. -.---- Iswonce Fee Q �- ���-- iDMA P/C N-� - - � �--- -� --=- - -� a bbove informotion is eorrect I agree to comply with all CooMy invasrigm�on Fea �� g ord�nonc s ond Siata laws ral mg to bu g ton1lrutlioo, ... " '_ .__ _.._..__ ... . _ .To�ol Fee- .•... _ : IDAM Perm.'M'- � "-''.' . .' u and he�6y aulhorixa repre lalives is CouNy to eMer � ' � upon e above-mpntio proparry r InspeUlon purposes. .�� .... .. -�- . . _ . _ � �. .._ .. . _ ...-- . _ / . . . - �- --. . _ _. _. .. ... __. . .__ . �'' / _L!� SEE REVERSE FOR EXPLANAiORY LANGUAGE � � ' ' " ..' _ - _-_'._, . .. .__ . .. _ .. . __ " "_'". . . ...._ __ �_ _ ..._ ... IQ.i _ t r PLANS TO`APPLICANT.�-- INSPECTOR'S NOTES , OL9NER-OUILDER DECLARATION .. I hereby affirm�hat I am exemp�from the'Contrador's Te: ' N�turn�d . ' � � . .. .� . �. . � License Low�for'�he follawing reason'. (Set.' 7031.5) � "� � - - - ' Approvad" � IIutinessanJProfessinnsCadc:AnyrityorrountymlicG No. Date � No. - � Da}�"�' �. . � �� ' � . . _.. requires a J+ermi!!o tonstrect,altes,irnprooe,Jemolrs5, , , . - orrepairanystrricture,friortoihissnanre,afsoregurres . ' . „ ,i,., , . .j�', the apf�litant for sucG pernrit to file a signed stalenennt 'd�nl Ge is lrcrnsed punuant to[Gc pmviaions of 1Lr Con- � C'� J�� ���, �'� f�'j-G �•� � . tractor's l.icertse I.aw(CGapter 9f(commencinq wilG Sec� " tinn 70001 n/Uivision 3 of 1bc Uusinrss aa6 f'rofessioni � � ' � ���� ��� � �" ' �� __,CodeJnrjla(bciiexempltherefrornandlLeba�isforlGe _ . _.. . _. ._ ._ __ - _ � _ _._.�._.__�_ _ _.._._.. ...._ _- .._. . a(feged exeniplion.Any piolation of Sertian 7031.5 by � _ _ . _ Required_. . peN Reufwd -.. �� ... �.. --. ... .. ' '-. ..- anyopplr�antforaperniresubje�lrlGeapplican[toativi( ; APProvals� Yai No or Apprav�d � _� '__ . �. . . _��_�'' .. .J�enally�of not more 1Lon fr've 6undred dollarr(fSODI.J:. - - ❑ I,os owner oF the property,or my employees with Water Certificafe �,� .'.� .' .',, � ' ��' . �.: . ,_. .. �_- .._. _ .. ....�.-' _ . •_'_. . . . . .wages as Iheir sole tompensalian,will do�he work,ond -- - - - - ' �� the structure is nor intended or offered ior sale(Sec.7044) � � Heahh�eportment _._ ,__ __ _. ._.�� ._ ..'_ �-� -. . - --.-�-�----- ---- ----. - ---=-- -� - DufinersandProJrssionsCodciT4eContraornr'sLrrcnse � Law Jnes not apQlv to an ou�ner of property wbo brsikls ' � � � .__ � or inr roi�rs t/rsenm,and uJ n Jnes srsch u�nrk Limsr"� . , Fiie Deportmen� _. - - -. _ , . . . � -- �--- . � . . . . -- --- •� . �.�.- -_._ h .. _ � � . � . .. � � , !1 roregb bis,ovm enrfrinyces, /�rooided lbdt sucG - , Grading _ � � � � " � � �,.Qrovemenfs are not intended or nf/ered fnr snle. 1/ ' ,. , , , , �•�Gnu�ee•eq 1l c builJing nrim/irovcnrerte iszo}d u•ithin nn • . . . ._. - . __ .. _ ._._. �.�� , . . .� �� . . '� f pl e t5 6 '!J !! Geological � . � � . .. . - ',ycar n conr c inn, e ou�ner- w er u�i bare 1! .. � busden of prnoing 1l�at br did not build or irnprove f Pede5lrian Pr , .. i . '_ ." _'_ _ " . ____-__ ._...._ '__._ : olection � � . , . . _ .. !be purpnse of sale/.':: � . .. . ,. � (Fence)(CanoPY) . '- . . � �.�.... . ��- '- ... . - --- -�---- --'- -' - -` -.:�.. ,';.�.'�❑ I.asowneroHheproperty,�amexdusivelymnlrac- �� ling wi�h licensed contractors lo cons�rut�the proje<t(Sec._ � . .- . . . . ... _ ._..� . ._ . - . ._.. _ _. _ . ..._.._... _-'�� ��7044)Business�and}'r�ssinns�Cade:Tfic�Contra�tnri Specioi Inspeciion " -. . .. � i (Cone)(Masonry){Welding) . �-- � , . , _ , l.icensc lau�does not afply to art oumer nf yrnperty u�ha - -� -- '""--'- - ".. .� - ---" - -"- .. .. "_� ._"-builJs or-imhroe�es lbrrron,unJ u�G<i conlraclt for rucb Lot Droinoge . � �� � ' � ; � � i_. . � , Qrojetts u�ilb a mrsfrarlor/sJ licenteJ J�rsrsuant to lfic , , , , _._ _.__. ...� _ ._ _ .._ .. . . ..,,. . � . �--�Cnnlracmr's License I,a�of.�- ��- �- -- - - Parking � '�r-.... . .... _-.. . _�.....�. �-- - -- " -�--�-��❑ I am exempi under Set. ,6.8P.C.for`iFii s y -- � -- - ---__ . __ . � ._ , : , � 6 rj � . . ,._ . . � fCO5Of1 .. _ . ..:. . . ... ...�... .... � ...' ' . _ �.___ � ,_ , Date Owner ,. . . , _�, . . . .__ . _ . . _ , , .� . . .., . . _ __. ___ .. .. .- -. ,. Approvnis Dafe �pacfor'�Stgnolun ! � ' � , . � � , - . � . � � . �INSPECTOR'S NOTES � Loco�ion— . - � - (Sel6ack 8 Yords �� -. �. -: .� . � " '�� " �- � • Foundalions �, . ... � ...� . � .�.�� . Slab . . ' �� . . . . . . � - �_____-._ ' . .• . . "' Frame . �, � ' . . ._.. .. . .. . .. . =��, . . . ,. ,. . . . Energy Insulofion �13„a7� . .��_._ ._S_.�.:._�__ ._ � ._.. ..__ _._J .:.�...: . .-, . .. .. ., . .. . ,. j � lath/Drywatl— �7 � / � _ . -.--, ... --- ---.._-- ---"-�- � -- � . Inlerior -?i^'C�� CY "`�f _._ . ._ • � � . . . . �a�h_Ex�e�.a, _2 C :_ - _. . - -_ _. . - � HouseNumber— .- ..._.. �.V:� .. •.. _ . ....." _..�_,"_~. � ., . . . .. -- ._..... Corrett 8 Posted . � - --.._ . �_.. �-.- ._ . .. - . final— � -- - - . . . �_ � � . ... �, _._ .____ _� _ _ .� � .• . . . , . . - Enler on Fron� -.. . •- '.�''\° , . . . � . . . . . .. � �_.,. �