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Home My WebLink About0934A 0935A (5) WORKERS'COMPENSATION DECLARATION � � � . �- � ` � . . .. . _ .. _ . . . . .. �� .�. . _. . _ � I hereby afflrm ihat I have a certificate of consent to self APPLI�C�I�T�IQN� �O�R� _B�JILDI�NG� PE�RMIT insure,or o certificote of Workers'Compensafion Insuronce, ora certified mpy ihe�eof(Sec.380'O,�Lab.C.) CpUNTY OF LOS ANGELES BUILDING AND SAFETY O�YNo61WETX799�ompany Hartfnrri Grnim ;/ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUIIDiNG f �{ )^tI�� Y� ,y` ADDRE55 /,)� N. �iJ�-� �" � Cerlified copy is filed wi�h the county building inspeo- BUI�DiNG - �� lion department. A�DRE55 1156 South Crestbrook Court oare-��appl�can� � � aTv Di amond Bar z�P �ocaurr CERTIFICATE OF EXEMPTIO FROM WORKERS' NO.OF BlDGS. NEAREST . COMPENSATION INSURANCE SIZE OF LOT NOW ON LO7 CROSS ST. - (This section need not be completed if ihe permit is for ane TRAQ 42568 g�OCK LOT NO. 54 �+SSESSOR - -kwncired Clollars($100)or 1e55.) MAP B��K PAGE PARCEL TE�' U5E ZONE 1J�AG ' i certify ihot in ihe performance of the work for which ihis OWNEe Bramalea Limited No. 85 -i � �7�`` Np, � rr�� } permit is issued,I shall not employ any person in ony manner � J so,os to bemme s�bjecf to the Workers'Compe'nso4ion�Lows. ADDRE55 3151 Ai rwa Ave. S l �-O'rv-B CUNDITIONS Q V Date Appiimnr CiTY ZIP � r"'^TICE TO APPLICANT: If, p4fer moking ihis CertifiCafe of ARCNITECi OR TE�� DISTRICT GROUP TYPE FIRE PROCESSED BY o ENGWEER NO. _ � nption, you should be<ome subject to ihe Workers' ��] CONST. ZO.NE v lompensation provisions of fhe Labor Code,you must forfh- qpDRESS 399 G� �u °�� with comply with s�ch provisions or this permit shall be TE� H deemed revoked. CONTRAC70R y' � NO. STATISTICAL CtA551FICATION APT. CONDO. � LICENSED CONTRACTORS DECLARATION �� CLASS NO. �WELL.UNITS I here6y affirm ihat I am licensed under provisions of Chaprer 9 ADORE55 3� � V O. (<ommencing with$ection 7000J of Division 3 of fhe Business and �� SEVJER MAP Professions Code,ond my license is in full force and effeci. CITY Costa Mesa CA ClASS gK � � VALIDATION n SQ.FT. NO.OF NO.OF CHECK . License Number 4�j�.yy Lic.CIo55 B SIZE STORIES FAMILIES ONE , � - ^ VAWATION Coniractor Rrama 1 aa �a�l�Date � DESCRIP7iON�OF WORK NEW �1 s /)��... �r}�� ADD �J / :��,7�.�S�� I om exemp�under Sec Sl Il 1 e Fami 1 Resi dence � _ � c ALTER ❑ .. ' ° ./. i B.&P.C.for ihis reason , REPAIR � S Date: USE OF 1 �ii l: ! I (I rye� / EXISTING 6LDG. PIOCIe �EMOL ❑ .. . S�anatur (� APP�ICANT TEL FINAL � .'••� i, i li�= e�VNER-BUILDER DECLARATION PRINT) Bruce L. Abbe NO. H5O-�OO� DAiE I hereby affir that i am exempt from the Contractor's License � � � �� i=U`rG d Law for ihe following reason(Section 7031.5,Business and ADDRE55 3151 Ai rwa Ave. N COStd M2S FINAL � ' Professions Code): �� pR g 7 By ��,�� f�T I, as owner of the property, or my employees with ADDRE55 � � wages as iheir sole compenwtion,will do the work and � � � � � � � , � � 'f;,Q�"�� ihe siructure is not intended or offered for sale(Section LOCALI7Y ' �" = ' �� 7044,8usiness-and Professions Code). MOVING TEL ._ y�„ e �r „ „ � � I,ps owner of ihe properiy,am exclosively contracfing CONiRACTOR NO. ' ' . _ ..__ _ . with licensed contraclors to cons�ruct�he projec�(Ser ' � , e�,��E%:1 j,V(`j tion 7044,Business and Prafessions Code). ADDRE55 CONSTRUCiION LENDING AGENCY SET�BAIX YARD HWY T�TApROP.L NEFROM W pTH � � -. _ :,E,�;<;;;:�y_ . I hereby affirm that there is a construction lending ogency for FRON7 � the performance of ihe work for which this permit is issued RL - ' " (;•i�,�rJ`�� (Sec.3097,Civ.C.). SIDE - P.L. m Lender's Name Teren�ke Bemi ni an �ank. �}} l LDMA Ref.N ' ' � 144 Sansome St. Su/i�t(e�/�700 --7�+^ - Lender's Address ��„ � �n p P.0 Fee S �✓I'd 0 Parmli Fes � C r� , I certify ihat I have Y�6tl iHi��ppnaa�i��On Si�fe'Th�YTfie !J �� Issuonce Fee !�� LDM4 P/C M � obove information is mrrect.I ogree to comply with all Counry Investigation Fee / � ardinances and Stafe lows relaling to building construclion, To�al Fee l7V -� LDMA Perm.# � and here6y authorize representatives of this County io enter � upon the above-mentioned pro erty for inspection purposes. +� � � � ..� � ��,�s` � SEE REVERSE POR EXPLANATORY IANGUAGE .• ignature of Applimnr or Aganr pa�e � � - � � �' PLANS TO APPUCANT INSPECTOR'S NOTES 0�4�VER-BUII.DF'R DECLARATION _ . I hereby affirm fhat I am exempt from the Cordractor's To: Returned License Law for fhe following reason. (Sec. 7031.51 Approved Business and Pro(essrons Code:Ary cltv or cossxty u�btcb No. Dole No. Dafe�� . reyaires u/+ermia to conatrucd,u76er,improve,demnlial, _. - or repair anystruciurq priar ta ita rssuance,also reyuires tfie app(icant for sucb permit fo jlfe a si,Przed statement tbut he rs licena�ed pursuunt to the prnvrsinns of dhr Con- �- � .� . .. ,. .. , , tro�tor's Lirense f.au�(Cbapter 9J(cnnn»:encing u�itb Ses�- tinn 7000J nf Dix+ision 3 oJ tbe 6usiness und Pro%ssinns CadeJ nr that Fie is exemj�t tberefrom axd t]e busrsfor tbe alle,¢ed rs.rvmption..Any niolmtinn of Sectiox 703/.j tiv Raquired DaTe Reeeived a�.Y�pPlican4 jor a/�ermit subjecG�the apqli�ant to a civi! Approvals or Approved penulty of no1 more Lhax fiae hundred rin!lurs(5�500/./: Yes No [ I,as owner of the property,or my employees wifh Water Certificote wages as their sole compensatron,will do the work,and the stru<ture is not intended ar offered for sale(Sec.7044) Heahh Deparimen7 � . . . - � Businnss andYrojessions Code:The Contractor'.s l,i�e�±¢.oe Lau�does not applry•to an numer of propertv u�l�o buidda- Fire.Deparlment � •- --•�- � �-�� nr impro:�es tl�ereon,anJ mGo does.rucb work binuelf or througb his ou•rs ernplr�yees, prnrided that sacG � - Grading � pro��emexfs are not intexded or offered for sale . !nv�ever,the b,ailJin,p or improvement rs.sold uitAix o.:e Geo�ogical 1'ear oj com/iletinn, thc nwner-buildcr u�r11 i�uve th<� . , : 5urden of provia,e r,hut he did nnt buidd nr imprnre for Pedesinan Protection - . tbe purpnae nf sa[e/. �Fence?(Canopy) '' - �. I,os owner�of the properiy,am exduslvely contrdc- ting wlth licensed controctors lo conshuct ihe pro�ecr(Sec. Spe<lol Inspecfion ' � 70a4)9usines.e and Projessinns Cnde: Tbe Cnntrticti�r's (Conc.)(Masonry){Welding) ' f icense I,aw Joes nntupply to un owner nf prnperty u�Gn builds ur inaprn:�es tl erenn,ursd irfio cnmtructs for a:sc! Lot Drainage . pr jacas u�itb a rr nara�tnr(,aJ licensed pursuant tn Lba � ., � Coxtractor's License LawJ. - Parking ' �� ' �� I am exemp'under Sec. ,8.8P.C.for this reason Dote Owner Approvals Data Inspector's SignaTure � _ _ � INSPECTOR'S NOTES Location-. �- ... . �Setback 8 Yards) fl.� � ""� Foundations `"E l�' - ' il-��r••r Slab � _L'�� Frame ��p�y /_�� - i�J�.r Energy Insulation Lath/Drywall— ' �"� � Interior -��f�' Lalh- ExPerlor )_�� - � � House Number � � � � . - , . � Corre<�8 Posted � � - Final-- En1er on Proni tQccJ%S A.�c-S J�v . it`5�t,Se�`h- G;i�Z o��°`�.