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Home My WebLink About0944A 0945A WORKERS'COMPENSA710N DECIARATION . .. ..... . . , ..` ..~. . . . .. . .. ..�„ �. - . . �..� ,:-��.�. . , . .� ... ._......` -� �'7 �. .. . .. _ . _ ... 'I hereby affrm thar I have a certificate of consent to se�f � APPLICAT"1C��N �FOR��BU�ILD�ING PFI�MIT � insure,or a certificale of Workers'Compensofion Insuronce, or a certified co �hereof Sec.3800,Lab.C.) � "�" � � 614P�TX799� Hartford Group COUNTY OF LOS ANGELES BUILDING AND SAFETY PalicyNo. ompany - � Cernfied copy is hereby furnished. FOR APPLICANT TO FILL IN ' '' Bu��o�NG ��J.-� ��,Z,�j'�' ��, no�Qess �v � Cerfified copy is filed with ihe coanty building inspeo- gUi�DING � �� ro�deparimenf. AD�RESS 1165 SoUth Crestbrook Court _f3 Dale��—Dl// Appliwnt c�Tv Diamond Bar z�P �ocnuTv CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. NEAREST ' � COMPENSATION INSURANCE SIZE OF LO7 NOW ON LOT CRO55 ST. _ (This section need nof be completed if ihe permit is for one a,..:'6 ASSESSOR '� hundred dollars($100)or less.) TRACT 42568-� a�«K LOT NO. 6� Mp,p BOOK PAGE PARCEL � TE�. USE ON �+P OWNER Br m 1 No. - r� No. I�R-� /� �^-3� � I certify that in the performance of the work for which�his � �d >' permit is issued,I sholl not employ any person in any manner � SPECIAL - � so as to become subjecf fo fhe Workers'Compensation Laws. ADDRE55 =�P'2'Y`d3 CONDITIONS o V c�Tr Costa Mesa z�P 92626 a Daie� AppliCani ARCHITECT OR TEL DISTRICT GROUP NPE FI2E PROCESSE�BY � .�"�ICE TO APPLICANT: If, ofter moking this Cerlificote of ENGWEER Aram Bassenian rvo.752-1864 CONS7! Z E V .mption, you should become subject to the Workers' / `�( W Compensation provisions of ihe Labor Code,you must forth- qDDRESS 3990 Westerl Pl. Sui te l70 G� �� ji> j j �d wifh comply with such provisions or lhis permit shall be - - ' - ' -'7EL. ' """ '' � STATISTICAL CLASSIFICATION APT. CON�O. Z deemeCl revoked. CONTRACTOR NO. - nq55 NO. �� DWELL UNITS �� LICENSED CONTRACTORS DECLARATION liC. - I hereby affirm ihat I am licensed under provisions of Chapter 9 ADDRE55 NO. . (commencing with Section 7000)ot Division 3 of the Business,and _ , �� SEWER MAP Professions Code,and my license is in full force and effecL Cliv COS'td Me a A «/+u BK. pG VAI,ID,(1SIQN � 54.Ff. NO.OF NO.OF; CHECK �N . License Number Q�.�Q,��.,�Cic.Class �B SIZE STORIES FAMILIES ONE VALUATION ^r °.�°L�i Contractor Rramalaa ra�if Dote oescRi��IOF WORK PLAN 23 �� A o � ; ��j �J�,� ! � �` `v � 4� �I om exempt under Sec. „ ALTER S ._ - ::G U.�' ! cz] B.&P.C.for this reoson REPniR u5E oF �j h i�-�-6 DptJe91:j EXISTING BLDG. NOI1e DFMOL � $ignature �� . _. rr�jr� APPIPRINT) NO. FINAL NER-BUILDER DECLARATION - DATE :��,�� I hereby affirm thot I om exempt from the ConTractor's License qpDRE55 3151 Ai rwa Ave. N �.OStd �25 FINAI � Law for ihe following reason(Section 7031.5, Business and _ Professions Code): � � � -""� BY =-ii''s 4'.-�}q - �� , I, as owner of the properly, or my employees wifh AD�DR 55 , wages as iheir sole compensotion,will do ihe work and ,, . `� ��4 6�'� � ihe structure is not intended or offered for sale(Section LOGqLI7Y 7044,Business and Professions Code). MOVING � - TEL ' . v:`i,�%v- � I,as owner of ihe property,am exclusively contracfing CONTRACtOR NO. ' '_ � with licensed cantraciors to'consirucl Ihe proje[t(Sec- qDDRESS ~ � y�G��1 lion 7044,Business and Professions Code). ' � � CONSTRUCTION LENDING AGENCY SET�BAC� VARD HWY TOTApROP.L NEFROM yyIDTH t��'-�C"-�i� �� I hereby affirm ihpt there is a constru<tion lending agency for FRON7 the performance of fhe work for which�his permit is issued P.i. (Sec 3097,Civ.C.). SiDE � P.L Lender's Nome T.oronto Domi ni on Bank �DMA Ref.# 144 Sansome St., Suite 700 P.C.Fees ,�.�2r�a '! Pe.m,fFee ��.�� ' - lender's Address • / r-� I<ertify ihat I have reod Ihis application ond siata fha�1 e /} �� Issuance Fee /J`v v L�MA P/C N � ¢ above information is correct.I pgree to comply with all County Invesrigarion Fee /�[y � ordinances and Slate laws relating to building construction, Toml Fee �T 1� �� l➢MA Perm.N ond hereby authorize represenfotives of this County to enter � upon the above-mentioned property f inspection p�rposes. 2. � �-�� ll�rl� �-�-� �,� � SEE REVERSE FOR E%PLANATORV LANGUAGE Signalure oF Applican�or Agent Dare ' ' . .. . : . .�� PLANS TO APPLICANT INSPECTOR'S NOTES OR'1ER-BUILDF.R DECI.ARA7'ION . , . I hereby affirm ihol I am exempt from the Contractor's To: Refurned � License Law for-the following rebson. (Sec. 7031.5) � Approved Busine.cs and Professions�'ode:Anry cily or cnun�ty u•hicb No. DaTe Na. Dofe " requires a nermit[n rnnstruct,after,improve,rdemalich, . rep¢ir nny s6ructure,prior tn its issuance,aLvo reguirea the applicant for sucl permit to fe'!e a signe`l.ctutement tbat he is liren.ceJ pursuavat[o the prnx•uions of tUe Com- � ,. , .� . .: . . � tracanr's I.icensc Luu•(Chapter 9J(rommencin,Q witL Sec- tion 7000J�f Dini.sion 3 of the Bussness and Professions Cnde/or 1Fiut be is exe»�pt therefrnm und ihe baris/or the ulle,qed exemption.Anv violatinn nf Section 7031.5 fiy� Required Date Reeeived uny appliranl Jnru permit subjects 6hc�applicant to u ri��i/ Approvals or Approved • penalty oj not more tfiun Jive 1 undred dollars(5j00J.f: � Yes No - �- [ I,as owner of Ihe property,or my employees with Wote�Certificate , � � . woges as their sole<ompensation,will do the work,and the slructure is not intended or offered for sale�(Sec.7044) Healfh Department . _. . . . - • Business and Prqjc.csians Cnde:T!e�Cnnt acdrr's License . . Lau doea�nnt upply tn an nu:ner nf fropert.y mho huilds Fire Depariment . >r improves tbarenn,uxd who dnes such wnrk brmself or � - � � , thrnug6 hes.nwn employees, prov'uled LLut sucb " Groding provements are mnt intended or fjered for sule, � � , � -�� _ , � . Fimoener,the lneildsng or i»eprovement rs sold u.sthin one Geologi<al Yea�'nf compledion, tbe nwner-fivilder u:ill bure the " � �� - �� burdan nf prnaix,q thut hc did not buifd or imprnve fnr Pedestrian Prorection . zhe purpnse oJsaTe). � .... (Fence)(Canopy) � � � -� ❑ I,asownerofrheproperry,omexdusivelyconfrao- . � ring wi�h licensed contractors to consiruct ihe project(Se<. Special Inspection 7044�13usiness a�¢d Prnfessioxs Code: Tbe Contracti�r's (Conc)(Mosonry)(Weldingl . f,icersse Luw�tnes not apply tn un numer of pmperty whn buildc ar imprn+rcv therenn,and u�fio cnntructs for iuch Lol Drainoge � /irojeds witb a contractor(sJ licensed pursuant tn tbe Comtra��tnr's License I,awJ. � - �" " Parking � � - � -��" �� '�� I am exempr under Sec ,B.&P.C.foriFiis reason ... . . . ._ ._.. . . . . . ....._ ___..___ ._,. Dme Owner ApP��a�s DaTe Inspector's Signoture � . . � "- - � INSPECTOR'S NOTES Location. � � . . (Setback&Yprds) ��- �' �' Foundations �� ` - � ` slab f r�.a 4-S . ... � �..... � �� ... ... , .. ... . Frame ,�t�� Energy Insulotion `G, � Ar- . �� r✓ lath/Drywall-- � � Interior �-�(-�7 Lalh- Exterior ��-d �;�„J - � � House Number-- Correct 8 Posted . . - . Final - Enter on Fronf ' � ' �- ' ' � '� � � � L'ccr-' 23-�` �s�., i~i�Jl-;�ati ��'7 /.1---