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HomeMy WebLinkAbout1238A -- _. .. ---- __ _.__ - - .._�. _ __ ___ ___ J ` WORKERS'COMPENSATION DECIARATION � � � � I insureborafrcertifcatteolWokers'tCompenmtonlnsurane" �►PPLICATION� FOR BUIlDIIVG F'ERMIT or o certified copy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicY�(„�'S'1'Z�Company Royi�al TTI(1- � ce.,a�ed coPY�s hereby furnished. . FOR APPUCANT TO Flll IN n��sess 1645 Butternut S� . y� Certified topy is filed wifh t co uilding inspeo- - gUII�ING� - � � � . �r tiOn deporimenl. ADDRE55 Da�e appl�mr,i " aTv Diamond Bar ziv iOCauiv L.� �Q�/ CE TIFI TE OF EXEMPTION FROM WORKERS' Si2E OF l07 NOw ON�LO7 C OSSSST. �AU�I �� COMPENSATION INSURANCE (This section�eed not be completed if fhe permif Is f on ASSESSOR - hundred dollars(5100)or�e55.) iRACT BLOCN (OT NO. µ4P gppl( - VAGE PARCEL TEI. U$E ZONE hN7 rr I cenify thar in the performance of the work for which this OWNER John Kamada No. ,�C_ � NO. �C���f^3 Y � permit is Issued,I shall oot employ any person In any manner L�j—V—J SPECIAL . � so as lo betome svbject la the Workeri ComPensOtiDn laWs. ' ADDRE55 . SrZIDQ 0 �ONDITIONS � Date � ApPlitant CITY ZIP � � - � NO710E TD APPUCANT: If, after mokin �fhis Certifimte of ARCHITECT OR TEI. DiSTRiCT GROUC TYPE iIRE vROCE55ED BY O g ENGINEER NO. CONSjr+ 2D � Eaemption, you should become svbjed.to the Workers' 1 ? 'J U Compensotion provisians of the Lobor Code,you musf forlh• qDDRE55 (� 12 7 y �''� W wi�h comply with such provisions or this permi� shall be deemeClrevoked. [OMRACiOR`�e`St'ern Sierra �O�ZI1�T STATISTICAlClA5]51F,ICATION A7T. CONDO. Z UCENSED CONiRACTORS�ECLARATION. � LIC. y� CLA55 NO.�OWELL UMTS I hereby offirm Iho�I om licensed under provisions oi Chopfer 9 ADDRE55 450 Apo l lo NO.�g 599 (commenting with Section 7D00)of Division 3 of�ha Businass ond ���, ��R�P � Professions Code,ond my license is in ful�force and eHecL CrtY - BTQS CLn55�,'� BK � YALIDATION $O.FT. NO.OF NO.OF CHECK LitemeNvmber 482599, . i;c.elass C3�� 52E - STORIES � FAMILIES oNe , . . VALUATION �o�nac�o� ��TP� Prn S� .TT��e ��+5/$? ; OESCRIDTIONOFWORK A D s 6,517.00 �� 23'8R ❑I om exempt under Sec. I e7it. shake TOOf W�th 35 S sE� , �{• • • • •� B.BP.C.for�bis reason i Of Sierratile ICB04361 REPAIR ❑ s � •�6 R�0 Dme: ¢zlst�iNc ei�c. R ns �E�� •p •b 8 0 0� Signoture ' - APPIICANT L. StTa.tz 'E�• 531—?00 FINAI I OWNER-BUILDER DECLARATION � vRiM NO. DATE (1��� Q�3� �$� I here6y affirm thot 1 am exempt Lom the CoMroctor's Licensa ". low for ihe following reason(Setlion 7031.5,Business ond , A��RE55 FINAL Professlons Code): � � � � g1' �' O6WLOING I, as owner of the property, or my employaes wilh ADDRE55 � wagesosthe�rsotecompensation,willdotheworkand ����T,, � Diamond Bar � , the structure is not inrended ar of(e�ed for sale(Seciion 7044,B�siness and Professions Code). MOViNG 1E�� � I,os owner of Ihe property,am ezclusively contracting COhIiRACTOR NO. with licensed contracrors ro consrruct rhe pro�ect(Seo- � - ppoaE55 - � � tion 7044,Business and Professions Code). ' CONSTRUCTION LENDING AGENCY - ' - SET�6ACK �ARD HWY TOTAp OP8 lwE WIDTH � I hereby affirm that there is a construction lending agency(or FRONi tha performonca of the work for which ihis parmit is issuad . P.L � (Sec.3097,Uv.C.). Si�e v.�. Lender's Name LpMq Ref.N Lender'a Address - - a.C.cee S� 7�rmn Fee � � I certify that I have read this applicction and state that�he . , � luua�ce Fss �(�. �DnnA P/C N � . above information Ia corrxt.I ogree lo comply wifh all Couny Invesiipo�ion Fee t' $ ordinance nd S�ote laws relafing to building cons�ruction, To�al f�• p � � tOhu v�.m.M � R and he y orize reprasenrat(ves of this County to enfer � � on e o - ent' d roperly for inspectio purpo s. �/ SEE REVERSE FOR[X►LANA70RY LANGUAGE � Signalure of Applicant e�� Dot �� � - � PLANS TO APPII[ANT INSPECTOR'S NOTES -�UlYN1iK-UUILI)F.It UP:CI.AKA7lU\ , , , , I hc�eby ofh.rn Ihcet I am eaempt Irnm Ihc Coreractor's To: . .. . Returned � � , , � ' � . , license low Inr ihe followiny rom,on (Sr.c�70]1'S1 � APProvod � �' � .. � . ��. .�� .�.. ltaaine.vsnndl7u/ra�inxs(:nJuAny�itl'on'nuntti'��•l�rt1� No. Da7¢ No. ' Date � � �.. - . � .- . . . � reyuirF�s n/�rrniif fo cunstru ! dlt r i nJ Jornuf��h. -- . - �=�ir rrpn�'r onr ieruuum,pr�or t�rt�i.�c .rn�e.�lsi�re y�urea �'!L� ''�t .� ' . .. � fl e uppfi�orit/nr sui L/�rrmit to filr n si,qnr:!at�tculrnf - ' '- - - - � - -- - -- ,•.thal Lr�.is lia�nsrJ/�urs«ant.tn tLr pr rsinn�r�d�r S:n � .":;'. ;1J:(i'.i�; 1 +71�1_�.�'.:�.�,1. frn�(nr'�l.i��•�lpl i�•(Cl�a �rr'J (conrn�en<in iu�l�.1t�' __ _ _. _ .. . . _ _.. . _ , �.-'_„�, l :_, ..• . . ., .. . . , . . �f::� .,1:(�..�J:I lc• . _ r ��4n1.f00flJ��dheer +r�ii�jfFrlJucin�scunJ!'ru/< <rnn� _._.. _ __ _ -..._'_. _. _ . .. ._ Gndr/nr:U�ul!i+.i cxr�rr�pl tb��rr/rnor unU thr 6pvio�%�r fl�e '_� ��� � „••� � equire0 `� ., . . . .__. _.� � �'. � .__ .._ .._. _..._ �. �.:f. �!/1��1'a��li:�dttt/ � n tUtub'etftf�•uC1/irrtrt(tMd:�n7 -- �--- --- -" � Dale�Recelved . . � �� , , PP . 1 1 fP Approvols . ' or Approvod .�. , . .: .. . '_ '�'f�uo!!V n(not�rrnn�t/uri l�nc 1��,�d.�d d���la.s/ctli�/IJ �. . . _�c. No � -�-� -� -- � � --- �� , �Yo ___ _._. _.. ...�_, .. � -, ' .� ' - ' (__. I,as ovme�of rhe p�oprrly,or my cmployc=5 wnh . . . � � .,r ..,. ..' ...• - 4'.'ale�.Ccr!ihcafe '.� ': ::.- �' ._ _.: .. �. • _.. _.__.. ._.__ . _ . _u.,. . . . - .� ..___._ . _._ .- .woges as the�r sole compensation.wdl dp Ihe wor4,and � � . the siruct�re�s aol intended or offe.red fo�sa�e.{Sec.7044; Heohh DePonmem-____. . . . ... . : � � ..... ._. ._.____._ __ ..�..� ... __.... . .. U«srnns.c and Prn/�•ssrnns Cudi•:7'hc Crintrarwr's Lkrnsi� eu«��,,����n„�ur�i,�„„R nu•ner nJ prnferte ir1�u huiALc Fi.e De anm.nt. . ... ._. .. .. ... . ::.. _,. . . ., . . -_or imfmrrs the�oun,and�r!o durs ra�J irnrk hirrrcc!ur p ..__ _ _._ I � � , . . lbrrm�6 Lis�nirn empluyee.e. prnrrd��d tl ut�su�L i+n. .. G•oding ? � �,.�'� " ' -�prnrvrnentr�arr nnt inlrnJcd nr u/IcrrJ/ur s�le. !f, . - . 'bo�rerer,tLabnildinxorirnprnne+nrnfissoldirid�inr�ne .. . . . , � � . ., Geolog-�cal � . ,. . .: , ..: .�..,,. .,�i7.:�.�.,_�1..,.�.:� � . ..:�„ � 1'�tir n/enmpletion, 1Gr bu�nrr.hvilJrr �ril!bnrr�the � � • � � -- . ' . ...__ . .. ..__ .._. _._ --'��_ ...-� hurdcn n/prnrirr,�1Lrr7 br d+d nn1 hui71'nr iurfrnrr/nr .._. .,. . _ _ .. Pedrstrian Prote�rlon. .� � � . . _ . . .. - .i.�.._._� :�i�i i. .. V�,s.� . IJ e pu�orc 6�.r�Jr1. . . 7. .. .��, ,�_ r . � , . (Fence�(ConopY) �� � .��. . '.. . -.. ._... .". ,. . ._-..-. �....-- � ., [_�. I,osowner of the properly,am eed�sr�cly contrnr.� ,,,i . . .ling wqh lice!xed wnlrncto,fo mnsrruc�Ihr.projeU�Sec. Speclal InspcUlan - ..- ..-. ..-. . .�. . -..�. _ .. - . . ._.-... _ 704a1llusinrssundlrnlruir n CnJr� �lhc Cnn»urinr's ' u (ConclfM�sonryl(Weldingl � ...._.'.�. . _ _ _ _ . _ Li«Hcri..,u�Jncsno�applt`i��ani+i�n�•r fpropertyu�/�n �. ... . -. . . .. _. _.__. . __ _ _. . , hurfds nr i�nprurrs tbrrrun,anJ irb���inntrares J�,r.n<<G . lot Drumorye ,.-� l�,.'��t;:.,:, � � - �.��.r---,. .:..... . . .. .. .... � /�`g.'us1 u�ith,¢a�mlr��tlrrj.al lJ..Au�id-purer..�rit fo thr 7 . i.° 1.. j�'(,•� -�. Cunlru.fnr's l.rreriie-L�ru�%. Po.king . , . �•- �' '_. _ _ _. _. _.__ ___-.- � �� . . - .I'.� ,v!.J.: ;l l„J � i:'i:� '.iu ❑ lame e ptunderSec. .B.BP.C.�forrh�s , __._ _ . .._.. .. . , . ... � �- . .. i ..,i.,'! ^<' '. � reasoa � _. ' __ _.._ _ _ ' ... ,�i �, .�. � . -.-- � _ .- . .--�-- - . ___._.. ._ --� , �.,, . , . '';J� . �nre Ov.ner . . . , .. . . ..�-1�... ::.I.,. .<< -..__ . _. _ ..___ ___ .__ __.._ �, - I -._ . . ., . .. .. . _ ' _. .._.. . .. ____. - '- -� .... � - :. .. -: .,�.. S_ , . Approvoln Dafo laspectar's SignaWro . . . .� �� . � � - � ' WSPECTOR'S NOTES � � �� � � . Loro�ion-- : "__ _._... ._ . _ f5e�backEYords) � ___.. . .:�._.. .::�II'1:..?J.i.. .,:i,,��.j ' _ �. . . . . .. � � ... Foondatlons ' _______ _.._._ __. . ':0�.��J;I�.t .._....___. . - n. , ,. .,. . .. -,� , . . Slob .. .. . . Frome . � � . . � . � ' . .. � . .. . , . Energylnsula��ion . . ._., _.._ _ �_ . ._ . .._. __ _._.... ._' . .._ .. . _ . .. . . � .. . � . . . . . ... . . � . Lath;Drywa'I.. ' —_'_.'__ ._ � . _ . . .. .. _ . . � Intcrlor . _ . .' '. � � , � . . ' . _.., � Loih-Exfer�or • . - � � , .. , _ . _..___.. .__. _..__ _ _._ _ .._ � .: r � ____._.__.. ._ _�__ ; i"_. , NooseN�mber_ . . ._., ._ _.__._...-... ._ ..,. � � . _..___.._.____ .___..... . Co.rect&Posted �: � . _ .__ ._.__ . _.____. -____.. _. . . -.. � ... . . , r,� Final_ �. .. . ......�. ,-. . . .� Enter on froni , . , .. . _ .� ., . � .... . , . .. ; .. , .. . . . _ . . �' - , � . . . .... . )'�'. 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