HomeMy WebLinkAbout0950A 0951A (5) WORKERS'WMPENSATION�ECLARATION � ' ��
. . ....... .. ... . .. _
�I hereby affirm ihat I have a certificofe of consent to self A �PLICATIOIV���FOR� BUILDING PERMIT
insure,or a certificate of Workers'Compensotion Insurance,
-.-
:
ora certi ie copy t ereo (ec. UILDING AND SAFETY
61 WETX7993 Hartfo.rd Grou CouN'rv oF�os ANGE�ES s
PolicyNo. Company p
. . -...... .
� Cerri(ied copy�s hereby f�rnished. FOR APPUCANT TO FILL IN Bu��o�NG ��r 6 �
ADDRE55 �.+ .
� Certified copy is filed with the county building inspec- gUI�DING � ` ` �
��o�departmem. y ADDRE55 1166 South Crestbrook Court
d _ ... ._._ . �. . . ._. _..__...._..�__...
�r .. _ .._...--� - --... ........ ... ... ..
Date — --7J Applicam CI7v Diamond Bar ZiP IOCAIITY
CERTIFICATE OF EXEMPTION FROM VJORKERS'r - NO.OF BLDGS. � NEAREST -
COMPENSATION INSURANCE 5¢E OF LOT NOW ON�07 CRO55 ST.
(ihis section need not L-e completed if the permir is for one - :'� aSSe550a�- -�
hundred dollprs($100)or less.) TRACT 42568. s�ocK �oT No. 55 �� NWP BOqC PAGE PARCEL
TEL. FF��771177 -g
I certify that i the performance of ihe work for which this OWNER � NO. _ US�� OP 1�r3 T y
permit is issued,I shall noY employ any person in any mpnner qDDRESS 3151 Ai rwa Ave. Su i te N � � SPECIAL - � 0.
sQ as to become subjecf fo the Workers'Compensafion Lows. > C� � CONDITIONS �
aTv Costa Mesa CA z�P �
Dote Appliconf 9262 a
1`p1"'-TICE TO APPLICANT: If, after moking this Cerfificofe of ARCHITECTOR TEL DISTRICT GROUP 7YPE FIRE PROCESSEDBY o
.nption, you shouid become subject to �he Workers' ENGWEER NO. - CONS ZQCI� �
l.ompensafion provisions of the Labor Cade,you must forfh- qDDRE55 �� �-; 2
wi}h comply wifh such provisions or 7his permit sholl be . �H
deemed revoked. CONTRACTOR Bramal ea Ca��f. NO. $5�-�Q�� STATISTICAL CLASSIFICATION APT. CUNDO. �
LICENSED CONTRACTORS DECLARATIDN � - �i�. CLASS NO.�DWEu.uNiTS
I here6y affirm thpt I am licensed under provisions of Chapier 9 AODRE55 3151 Ai rwa Ave., Nn,o. 4�9610 SEWER MAP - � -
(commencing with Sedion 7000)of Division 3 of the Business and LIC.
Professions Code,and my license is in full force and effect CITY C1A55 BK � VAIIDATION -
SQ.FT. n NO.OF NO.OF. . CHECK
I,icense Number /Il�O�__Lic.Class $�'� SIZE � y� STORIES 2 FAMIlIES � . ONE
f VALUATION
Coniractor Rv�am�l o� f�l i f Date DESCRIPTION OF WORK - PLAN Z R NEW G� _ �J� �'7�JL .
. ' ADD � � / , :�(�t/5 Ci�F�,
�I am exempt under Sec. ❑ r ,
ALTER � c c.� I
B.&P.C.for ihis reason W 1 REPAIR ❑ s
pa�e use oF i 4 3 c G.li.i
J EXISTING BLDG. DEMOL ❑
Signaiure L � ��/'� APPLICANT TEL. FINAL ' �%'-'�1 u. I �'
OWNER-BUILDER DECIARATION PRiNT NO. - DATE G�rl-�i 7 �
I hereby affirm thot I om exempt from the Contraclor's License qDDRE55 3�5� Ai rwa Ave. N Costa M S KINAL ' - �'t'r(i-2i f'i ,
Low for the following reason(Seciion 7031.5,B�siness and �
Piofessions Cade): '� ' T By
.'4�� I, os owner of the property, or my employees with ADDRE55 - '
�
. ... .. .. . . . . _ ........... .. .. ;.
wages as�heir sole compensation,will do ihe work and
the structure is not iMended or of4ered for sale(Section LOCALITY ' � c!j��.I F�;
7044,Business and Professions Code). MOVING � � �� TEL� .
� I,as owner of ihe property,am exclusively controcling CONTRACTOR NO. . ,. „ , �
wiih licensed coniractors to construct ihe project($eo- qppRESS `
tion 7044,Business ond Professions Code). - i ��(.'.y',Q�
CONSTRl1CTION LENDING AGENCY' ' " SET�BACK YARD HWY T�TP'pROP.ALICNE'ROM y��DTH x'
f here6y affirm that there is a construciion lending agenry for FROM �� � "-
ii.G.l�.,:j c:
the performance of the work for which this permit is issued p.L. � - - -
(Sec.3097,Civ.C.). SIDE ��`^r��-""C=�% '
P.l.
lender's Nqme Tnrppt0 ��i117117�YL Q[111�_ LDMA Ret.#
- Lender's Address �p cr r�
144 Sansome St.> Sui te 700 P.C.Fee$ ��-�'/ Permit Fee •38-�7J ,
I certify that I have r d?f'thi a����tibTf'Shd e a ��r� Issunnce Fee �"�� LDMA P/C#
¢ ab ve information is c rrect.I agree to comply with all Counry in�enigmion Fee
ordinances and S�ate lawg relpting to boilding wnsiroctioa, To�ol Pee �� LDMA Perm.#
ond hereby outhorize represen�atives of this County to enter
$ upon ihe abo�e-menfioned property for inspection purposes. � � � " �� ' �' - " �'
e J��//t/!J�/J� �'�-�� ^'��j SEE REYERSE FOR E%PIANATORY LANGUAGE �
� -' Signor�re af Appliconi ar Agen1 Date - ' n�
� �
i
PLANS TO APPLICANT INSPECTOR'S NOTES OR':`iER-BUILDER DECI,ARATIOM1
I hereby affirm thot I am exempi from the Controcro%s
To: ReWrned L�wnse Low for ihe following reason. (Sec. 7031.51
Approved Business uoul ProJe.rsions Code:Any city orcoun{y ubicb
No. Date No. DaTe� requi a permit en ronstrxct,alter,zmprnve,demnli.�-b,
. br repair any structure,prdor to its zssuanm,ako reyurre.e
the appliramt Jnr such permet tn Jrfe a srgned stutement
that he is[icensed purseeant to the prnvisinn.c ojtbe Coix-
- „ -. ., � � �. ,� � aractor'.sl,icensel,au�(Cbapter9J(a'o»amettcrngu•itb.Set-
�'tinn 7000J qf Uiuisinn 3�f tfie Business u�nd Pro%ssinns
� � --�. . CndrJ or t1 at he rs exe>n¢t therefrom and tl e basis/or Lbe
� alleged creraytion..Any violalron of Sedion 7031.5 6v
Required Dofe Received any applicnnt for a(iermit subjects tbe up(ifrcanL to u ci:�if
Approvals Yes No or Approved , _ �.f�exalty n/'nnt more than frce Gundred dr�/lars(3500)./:
❑ I,as awner of ihe property,ar my employees wilh
Wa!er Certificate . , , . ,_. wages as iheir sole compensation,will do 1he work,and
the slructure is not iniended or offered for sale(Sec.7044)
HeaNh�eparrment , �Bxsiieess¢nd Prufessinns CaJei The Cnntracfor's Lfcense
l,aw dnes xr t apply tn an oumer oJprnperry u�i n builds
FireDeparimenr nr'mproaesl.Lereon,andwhodressucl wnrkbrmseljor
tJrnugb bir ou•n ompinyees,pmvided tbud such �--
Grading � � �ro+�ements ure not inde�nded nr of�ered fnr sola
� ., . . � bou.�ever,tbe bufldin,g or improrensvnd rs aold u�itbin o�ie
Geologiml yedr tf rnmfiJetion, t!e o¢�nar-bu1lder u�ill havv the
, ` burden qJ prnaixg that bc rdid reot build nr impro:�e/or
Pedestrian Profeciion . ��
� .. ._ . at�e pu pase ujsale/.
(Fence)(Canopy) - �� I,as ownerof the property,om exdusively conlror
'fing-wi!h licensed coniractors to consiruct the project(Sec.
� � 7044)Bresiroess¢nd Profu�srons Code: 7'1 e Contractnr's
Special Inspection I.icense L,uae Joes nof u /y tn an oumer nf erty u�fin
(Cone.;(Mosonry)(Weldingl - �burld.s nr imprne�es tbcr on,and u•fin e�nt ue�f�r sneh
Lot Drainage /�r jectr u;ith u rnntractur/s/limv�seJ pursuant tr� tbe
Cantructnr:c License Lau/.
Parkinq - � . - •. .. . . .
❑ Iomenemptunder5ec ,B.BP.C.forthis
reason . ... . .
- - Dofe � Owner
Approvals Date InspecMr's Siqnature .. . �.:'.,.,-.� .
.. ..... .. .
� � �� � INSPECTOR'S NOTES
Lomtion . , _
(Serback 8 Yards) �/ �
`��
Fcundotions "� �
Slab �i ��4�dCi t/ . . . . . . .. .
F�ame ��a,�� �,�_ ,..� . . �
Energy Insulalion f�4^� � � - �- -
Larh;orywall�. � . . .
Interlor -Z � _ .
Lath--Exterior � -� . .�. � � . . �
s—t(�� �v
House Number - � '� - � ' - . ,.
CorreU&Pasted -"
Final . . ..... .. ._..... ...:........ ..
Enter on Froni � � �
_.:.......... .��.��,n. . ... .... .......
�cct= S —�o�-�/ . .
fi%xrsr�.-� �zs�ti �