HomeMy WebLinkAbout0898A 0899A WORKERS'-COMPENSATIONDECLARATION � � "'- -�., ..-,. � �. G`"l
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I hereby affvm thot,i hvve a cerfifica�e of consenf to self A�'PLIC�ATION FOR BUfLDING PERMIT �
msure,or a certificore of-Workers'Compensat on Insur66ce,
or a cernf ed co thereof(Sec.3600.Lab.C.) " � �"" � � �� "� " -'�-' '�' "'`�" � - �
61W�TX799�3 COUNTY OF LOS ANGELES BUILbING AND SAFETV
PolicYNo. ompany_,Hartfnrr� Grrnm . - �.:. .....: . -...-��-` —�---_. ._. ..
� Ceriified copy�s he�eby fu���shed. FOR�APPLICANT TO FILL IN � A�p�� %' �°.{� '�.� �� ,
C;1 Certified co s tiled wi�h�he count 6uildin " � � �"--' �"�"-�"��- '"� "" " �
py i , y g inspec- BUILDING�
��� ,�a�depdrtmenf. AODRE55 1 i 79 South Crestbr ok Co r �/3•
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Date'U `�y=��Applicont /A CRY Diamond Bar LP LOCALI7Y
CERTIFICATE OF EXEMPTION FROM WORKERS' ' � NO.OF"BLDGS. � � ' NE4REST . .. .
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CRO55 57.
(This seciion need nof be completed if the permit�is for one � ���� ASSESSOR �".
hundred do�lqrs($100)ar less.) TRACt 2 BLOCK LOT NO. ' (�Ap,p gpOK PAGE PAR(EL
' TEL. U�F ZONE ��
OWNER NO. �J�_
I certify fhaf in the performance of the work for which this - 6t�}� �� - y
permit is issued,I shali not employ ony person in any manner r SPECIAL d
sa as to become subjecY_to the Workers'Compensation Laws. /+DDRESS ��Q0�7 CONDITIONS V
Dafe �Applicont CITY ZIP �- � �
,�TICE TO APP�ICANT: If, after makin ihi5 CenifiCate of ARCHITECTOR TE�� pISTRICi GROUP TYPE FIRE PROCESSED eY o
nption, yoo should become su6ject to the Workers' ENGINEER �� - /y COf�S�YJ/ ZfONE (~j
C.ompensation provisions of the Labor Code,you must forih- qDDRE55 " � �'� ,i'� 1 � �
with mmply with such provisions or fhis permit shall be � � �-����-- � TE�. � -�� �� �
deemed revoked„ COMRACTORB �p � � f NO. STATISTICAL CLAS IFICATION APT. CONDO. Z
LICENSED CONTRACTORS DECLARATION � �� - ' �� - CLA55 NO. DWELL.UNITS ��
' 'll"Ci'.'
I hereby offirm�hot I am licensed under provisions of Chopfer 9 nooRess �3151 Ai rway� N No. 409670
(commencinq with Section 7000)of Divisio�l 3 of the Business ond � � . ���-• • SEWER MAP
Professions Code,ond my license is in full force and effect. CITY Costa Mesa� CA ��q� �s� B VpLIDAiION
- SQ.FT. NO:OF � �y NO..OF CHECK BK� �'� � !
License Num6er (I,�q��� Lic.C�ass $ SIZE � 37 STORIE$ L � FAMILIES �� ONE . . �-`��'4'�r�
� �- �� - � VALUATION
Coniroctor Bramalea Cd�lf.Dofe - DESCRIPTI N OF WORK - -' � A D s �:�F �'/�� n ' ^ c�I -
6�O f/ ,
�I am exempt under Sea � ��u`�"� ,
AL7ER
e.&P.C.for this reason N2W Constr tl i� gEPAIR S `_•'� � '�'
- Datej�� �—�-- USE OF DEMOL
.('�+�� (�(iSUt V�/dw✓ EXISTING BL�G. ❑ ���C Ci'U U �
Si nature APPUCC,NT �-� - � � 7EL. -
9 v cRiNT� Bruce L. Abbey No. 850-1001 FINAL
�WNER-BUILDER DECLARATION _ _ , DATE S y(^S�
� I hereby af4irm thql I am exemptfrom ihe Controcfor sLicense qDDRE55 3151 Ai rwa Ave. N Costa Mes �
law 4or fhe following reoson (Section 7031.5,Business and s e FINAL
Professions Code): a ESEM .. . - ".....-. - " ..'-. .. BY /� �
y, my employees with ADDRE55 �^��j C.C+F.
:`� I, os owner of the properf or BUIIDING
wages az their sole compenxation,will do the work and � �'� � ��'�'- � "����'�� � ' �
the structure is not intended or atfered for sole(Section LOCALiTY , r
7044,Business and Professions Code). ' MOVING ' ""' - ' TEL. � � ¢���- � � � E
� I,os owner of ihe property,am exdusively camracting CONTRACTOR NO. ' � „ �G. -
j's"•'-�;.�::..
wifh ficensed coniractors to consfrucf ihe project(Sec- qDDRE55
tion 7044,Business and Professions Code). � „�A`;`•G ,
- CONSTRUCTION LENDING AGENCY REQUIRED yqRD HWY TOTAL SETBACK F M EXI 7. � � �' . .
SET BACK PROP.LINE WIDTH
I hereby affirm that there is o consiruction lending ogency for FRONT � �+�>,��a••��,
the performance of the wark for which this permit is issued p.�.
(Sec.3097,Civ.C.). SiDE .
. . v.�. .. . . . .
Lender'sName Toronto Dominion Bank . . .
LDMA Ref.#
144 Sansome St., Suite 700 P.GFees �fS�.� PermrtFee 7�. � '
- Cender's Address
an ranc7 s[�o ��L
I certify thot I have read this appficaTio�an siate ihaf 7he _ ��f�jF �-r'� Iswance Fee �o� LDMA PiC#
¢ above information is correct.I agree to comply wifh all CouMy Investl Kon Fee f� �
= ordinances and State lows relating to building construction, 9� Toml Fee " �'"� LOMA Perm,# -
and hereby authorize representatives of this Counry to enter
opon the above-mentioned propert for inspection purposes. ��'� ' "" � h�__� �� ' ' �� �
�(/� )�{ /'� �(// �'�•�
^ —���' 1�.,.!!l `-�/Y-� SEE REVERSE FOR E%PLAMATORY LANGUAGE
Si Iure of A lic�or+A, ��—� � - � - � �
9^a PP 9ent Do�e
� �
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� PLANS TO APPLICANT INSPECTOR'S NOTES OW'NER-BUILDER DECI.ARATION
I hereby offirm rha�I om exempt from ihe Contractor's
To: Re}V�ned � �" L'icense Law for fhe following reoson. (Sec. 7031.Sj
� Approved Business and Prn'fessions Code:Any cfty orinunt,ry�u�fiicb
No. Dafe No. �a}e - ' ' � � requires a pern+it tn ronstrru�t,alter,im/�rove,denrnlish,
- - , �dr'repair any structure,prlor lo i1s issrs�ence,aJsa reyuires
� . the applicant Jnr sucb pesrmit an f7e a signed saatement
"' --��-� ��-"�-- ' "-- t!at be is licemced pursu¢nt to the provisions nf the Cnn-
. � � .,. . •�' '� - ` ' . , . truclor's L.ecensa Luw(Cfiupter 9J/commencing u�itb.Sec-
tiun 7000)njDivisinn 3 of the Busrness and Prof�.eeinxs
� � . CudeJ or tbal he is exempt tbercfrom and tbe basu jr r abe
- a!leged e.remprdnn.Any x•inJation f Section 7031.5 6y
Required DaTe Reeeired � " � un��applicuxi f�r a pern�it subjects the applicaxt tn�cir»!
Approvols or Approved �:pexaltp uf not morc�tban five bundred dollars(5J00/.I��
Yes No � ' � - .
" "-'""""�"� � Li I,as owner of ihe properly,or my employees with
Water Certifimte . � ��� � _ � wages as iheir sole<ompensotion,will do�he work,pnd
- � � the structure is not intended or offeled for sale�'(Sec.7044)
Heal�h Depanment •� .. . . � . . , - . Business und Prnfessrnxs Cnde:Tbe Contructnr's�License
l,aw dnes mnr mpply to ax owner nf property u�bo huifds
Fire Deportmeni � - - nr rmproves thereox,ax�l�cbn does sucb v.�ork 1 imse[/or
� .. - tbrnuqb his ou.n emp[og�ees. prneidad abat sucb �-�-
Grad�ng ,�.-•—..._,` � � �"" �� " pme�emenas ure not rnaended or offered for sule
-s�`�--- - . -� . hna�ever,tfie huidding or improrement i.r so[d witl�in nne
Geological / year qf myletron, tbe nu.•ner-huilder milf bave tbe
!� �.� ,�GGI"'� �% y� � burden o(prourm,�tbat he did no1 build or improoe for
Pedestrian 7rotection � . .. [bepurJ�ose ojsmfeJ. -
;Fence)(Canopy) 1 S/�/��� Y/. �i ti 1'v� �, I,as owne�of the property,om exdusively contrdc-
� � � � +ing with licensed contractors to conslruct the prolect(Sec.
Special Inspection '\ �-��-� � � � 70d4?Bu�iness and Prnjeiiinnx�Cnde:�Tbe Cnntrucanrk
(Conc)(Masonry)(Weldingl ,. I.icense I.uu�dnes nntapply tn�ux av�ner rf�roJierty iuho
- ��• builds nr improves iherenn,aud u�bn contracis Jnr such
Lot Drainage prnjecta u�itb u rnn6ractor(sJ licerised pursuanl to the
Conlruotnr's I,:cen,ce I�eu�).� - . . ..
Parking . . . . . - � . :. .
� I am exempt under Sec. ,B.BP.C.for lhis
reason . . . ..,..... . . . .
Date � � Owner
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Approvals �ate InspecTor's Signafure � - ... .. . .._.... .................__ ..., ,.., _., . �
... .._. ..._....__.,
'' INSPECTOR'S NOTES
Lomhon-- ��� � �
(Setback&Yords) ii� � ,
Foundalions � �
slob G '��._tZ.-S7— �..<-+-- . . . .. -
t.::.,
Frame ._Z�� . .
Energy Insularion 2 C r� ;'/_ ,�� , ; ,--"� ' "� - .
> t'i�
Lath/Drywall-� -� - -
Interior y� �)-f,� -
Lpth—Exterior 3^,6 j . � � � � � -
House Num6er-� ' � � "
Correcl 8 Pos7ed ��L-- �
Finol - - � . � .. ,.... ... .. � :.- :. ..-.,...�.-, � .
Enfer on fronl �- � �
r2�u= 2_�'i "7 /�.�yi� . � . .. - . . . �
Lr3�:%-+x.�'.r �..t(_��7 ' . .. .. _.. . . . , . .
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