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WORKERS' COMPENSATION DECLARATION
ent to s
insurebor affcertifcatte of Wokers'tCompenaton Insurane, APPLICATION FOR BUILDING PERMIT
or o certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
acy-IK%rQj L.DZ0ZI company Royrla.l ind
-
Certified copy is hereby furnished.
y� Certified copy is filed with t co uilding inspec-
tion deportment.
Date Applicant
CEkTlFrCkf OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is f on
hundred dollars ($100) or less.) -
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person In any manner
so as to become subject to the Workers' Compensation Laws.
Date - Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject . to the Workers'
Compensotion provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensedunder provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 482599, Lic. Class C39
Contractor IVPqtern Si .rrpate 8/25/87 ;
F1I am exempt under Sec. I
B.BP.C. for this reason
Dote:
Signature
OWNER -BUILDER DECLARATION `
I hereby affirm that 1 am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY - -
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address -
I certify that I have read this application and state that the
above information Is correct. I agree to comply with all County
$ ordinance nd State lows relating to building construction,
R and he y horize representatives of this County to enter
FOR APPLICANT TO FILL INBUILDING
ADDRESS 1645 Butternut Wy.
BUILDING -
ADDRESS 1645 Butternut Wy.
CITY Diamond Bar ZIP_
ocaurY k.9 IAC,`
I 56—
SIZE OF LOT NOW ONLLOT
C OSSSST. 94JI2
ASSESSOR
TRACT tt BLOCK LOT NO.
MAPBOOK PAGE PARCEL
TEL'
OWNER John Kameda NO.
USE ZO (E
.(
L
0
MAP L^
NO. d d ^ 3 l
ADDRESS same
SPECIAL
CONDITIONS
CITY ZIP
-
ARCHITECT OR TEL.
DISTRICT
GROUP
TYPE
FIRE
PROCESSED BY
ENGINEER NO.
?
I
CONSj++
ADDRESS
12 7
f`
Western Sierra aOofing
STATISTICAL CLASSIFICATION
APT,
CONDO.
CONTRACTOR
Q ASS Nu.OWE'- UNITS
I
LIC. 49fl 599
ADDRESS 450 Apollo NO.
SEWER MAP
CITY Brea CLASS C33
BK O VALIDATION
SO. FT. NO. OF N0. OF CHECK
SIZE - STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK NEW
i 6,517.00 , 2 3.8 A
ext. shake roof with 35 s As
, t1 • • • • • 1
a
of Sierratile IC1104361
REPAIR ❑
$ I• -6a 0
A A.6800z.
FINAL I
DATE('� 5.t7 0a31-87
USE OF
EXISTING BLDG. Residense I DEMOL
APPLICANT TI Stratz No 531-700
ADDRESS
FINAL
By t
PRESENT
BUILDING
ADDRESS
010,MOVING
LOCALITY Diamond Bar
TEL.
CONTRACTOR NO.
ADDRESS
REQUIRED YARD HWY TOTAI S11BA K FROM
SETBACK PROP. LINE WIDTH
FROM
P.l.
SIDE
P. L.
LDMA R.I. N
P.C. Fee S Permit Fee
Issuance Fee ro .
ON P/C N
Investigation Fee (�
fee
Total 6
LDMA Ps. N
on e o - ent' d roperty for inspect,107 pu,polfs. /7
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant enr Doleft/ -
K
PLANS TO APPLICANT
INSPECTOR'S NOTES
To: .. Returned
No. Dale No. Date
Approved
-
PPr s
A oval Yox.
'DaleRecelved
or Approved
_.
..'
Signature'
--"- -"--
- _. - _.. ... .. .... __ _. ':...-.. •.
_- No
V.'ale•. Certificate
Health Deperim—t-..
Fire Department. ...._. ... .... ..
.. .. .
Geological
Pedestrian Protection
(Fence) (Canopy)'
Special Inspection_-
(Conel(Masonry)(Welding)
Lot Dru,noge
Parking
Approvals Date
Inspector's
l5etback&Yords)
_.__.. .•_'.. ::t1'1:..?J.i:, ,:,•J .I- _' .
F—odatlons
Slab
- -
Frame
.... ., .., .•. „.
Energy Insulation
- -- - .
I
.
Lath; D,ywo'I ..mor—
Interior
- -
Loth –Exterior
Lot',
-
House Number–
Correct & Posted
i s
Final -
Enter on Front-
-
- OWNER-BUILDhK DE:CLAKAIFION
I hereby affirm Ihot I am eeempt tram the Coo•ractor's
License Low for the followmg ram,on {See. - 70]1'5)
Basinessend l'ro/rasinxs (:ode: Any,rit l-or.tnuntvr l,01
reyuirt•snrrrnrit to --l— t elt� ,r,tj Jorrm(Ah,
•--1=1rir rrpnrr one ierurturr, prrnr t'; rti iic rinro, else rl yurrel
Me applicant fr+r suede permit to file a signeJ atat rolerit
,that be'.is bcensrJ pars uant.to the prnt•rsinns r f the S.n
( aaor', 13 -nip l o• (Cl,apler )%(pn rrr,emitt.q with
it4 n r'.r(1(lflJ r[d) r. M!"
+r�i,j the Businsss and Pruf
nrr<snrn,
Gndr/azul ! s. ,M!" pt thrrr/roar aria (he the
��allGgcd e.rcnrptinn.'Anl•.t lnlatinn r f 1�thnrt ir131.5 hr
davapplicanl/ tpernrit nrbjreft fhr upprirrtri(tna:n•il
f�rial(v of net r 7/—, /nr hand—J dollars ($500)
L! I, as o—er of the property, or my employees wo}s
,wages as their sole compensation, will do she —4, and
the siructare is not intended or offered for sale.(Sac. 70.14)
!.sines and P,40sinns Code: 7'hc Co,,i—dsr's Licrnsi•
l.au• dors not apph, to an owner of property u•1•u bui4Ls
_ _or improv, s rr r -n, and a fin does sr 1 rte hinurl/or
rbrrrugh his -men emphrpees. Provided tb.t-cb ira-
- prnrern-fir Marc not intended or offered fur sale. If.
borrerer, tbal ildinx or inrprnnernrht is sold within one
face n/—pletion, Ibe 'owner -builder trill burr the
burden n/prenirr,q that be did riot build'or inrpr—e for
tb, pa moose bf.re(el. -
t
L as owner of the property, am exdusr�cly contlac-
.ting wqh licensed conlroctors to construct the. project (Sec.
70441 Business and Profrssiun, 'Code- 'Ibe Caritraetori
14,en r-l.au• dors not apprt`f%Sni+i2rirr (property who
builds or irnpreves thereon, unJ u•bo'contracts Jur ,sulh
�.pk sfrus1 with a amlrar tpr(sl lie.Au �, d-pureu.rnt to the
6,rreracror's I.icehsc-L,ier%. - -
lamexemptunderSec. B.&P.C. forehrs
Date _ - Ov.ner _
INSPECTOR'S NOTES
.mss. .�. ..... ..