HomeMy WebLinkAbout1788A 1789A . . . .._ _ . _.. .... [-
WORKERS'CO'MPENSATION DECLARATION � J�O
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I hereby affirm that I hpve a<ertifimte of tonsent to self Qp�p`��CATIQN���FOR BU�ILDING�PER�MIT
, insure,or a certifi<ate of Workers'Compensation Insurance, _
or a certified copy thereof(Sec.3800,Lab.C.) � � " �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
��yNoPWCC253824dd�,Pa�Y Pac. Employers �p n
Certified copy is hereby f�rnished. FOR APPLICANT TO FILL IN � '� aooeess `.��/ , eG(/�J'ytil /".R-�zti
� _. _... . -
Certified mpy is filed with ihe cou y building inspeo- BN�DWG r^ (� �y
fion depariment. ADDRESS v ��.7 �� �N
Dote���2'�Applicant� CITv Diamond Bar zia 91765 iocnuTv
CERTIFICATE OF EXEMPTI OM WORKER NO.OP BLDGS. NEAREST - . .
� COMPENSATIO I URANCE SIZE OF tOt NOw ON LOT —O— C&055 ST.
(This section need nof be co eted if the permit is for one /+SSESSOR
hundred dallors(5100)or less.) TRACT � BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. U ZO �P /
I certify that in the performance of the work for which this OWNERNj B N �/1 a���� � sP GiAL ``�r� �
permii is issued,I shall not employ any person in any manner P,Q. $OX 3rJ� a�-m'TiTt�
so as fo become subject to ihe Workers'Compensation Laws. ADDRE55 CONDITIONS �
arr Brea CA ziP 92621 Ac
Date Applicant ARCH17ECi OR TEL O
NOTICE TO APPLICANT: If, after making ihis Certificate of y„C. �'OYS & AssocHo.862-8177 DISTRICT GROUP ivaE Fiz� PROCESSEDBY �
!'�Yf�"?mption, you should become subjed to the Workers' ENGINEER P CONST. (yJ �
�mpensation provisions of ihe Lobor Code,you must forth- qDORESS L�8�F1 S. Paramount .'�.VB. DOWIl@ I� �'•� � .1sf' �
with comply with such provisions or this permit sholl be ' TEL�- -� �� STATISTICAL CLASSIPICATION AP7. CONDO. Z
deemed revoked. CONTRACiDR Ocaner NO. -�
UCENSED CONTRACTORS DECLARATION ii�_ � CLasS NO. �'� DWELL.UNITS �
I_here6y affirm ihai I am licensed under provisions of Chapfer 9 ADDRESS NO. SEWER MAP
(commencing wifh SecYion 7000)of Division 3 of the Business and - LIC.
Professions Code,and my license is in full force and effect. CITY CLA55 BK � VALIDATION
$Q.FT. NO.OF NO.OF CHECK
,L�cense Number SL�tiL�R L�c.Class Rj � 5¢e sroRies FAMILIES ONE 'C
- . . . .�, VAWATION ' ��.�'F' �
DESCRIPTION OF WpRK NEW
Con}ractor Date ADD � ; ���� �'� r`o c e e�(�j
❑I am exempt under Sec. with at'tBChed aTa e ' �
ALTER � i °��•i.�'.�
B.BP.C.for ihis r�son REPAIR � s � :. o f;c5 ,r,'i,�.ti
/ USE OF_ . "'
Date: EXISTI� �DG. �� A DEMOL ❑
/.� _ APPIICAN TEL. �S�C�`S O
Signature � ` FINAL y_(�
WNER-BUILD �ECLARATION PRiN '].J. Brock & Sons NO.SZS�—g1�O DA7E _�J Q f
i hereby affir thot I om ex mpt from ihe CoNractor's License P,Q. $Ox 350, Brea, �'.3 9262.1 '
Law for th following reason (Section 7037.5, Business and ADDRESS FINA
Professio Code): � PRE EM � BY ,
I, as owner of the o ert or p y BUILDING
,f..� pr p y, my em lo ees with ADDRE55 . „ . ..... .-. i 1�5,.�,''A
wages as their sole compensation,will do the work and
rhe structure is not infended or offered for sale(Sedion LOCALITY , � ,� q �, � y
7044,Business and Professions Code). MOVING 7E1.
n I,os owner of ihe property,am exdusively controcfing CONTRAG70R NO- i a s�, i p,�G
4{� with licensed conirocrors�o consiruct the project(Sec-
iion 7044,Business and Professions Code). ADDRESS „ o•�,5+� ��,rj(';i
REQUIRED TOTAL SETBACK FROM %t T. � �
CONSTRUCTION LENDING AGENCY� � �' �7 gq�g YAR� HWV pROP.LME WiDTH
I hereby affirm ihot there is a consiroction lending agency for FRONT 'G'r1����C
the performance of the work for which this permit is issued P.L.
(Sec.3097,Civ.C.�. SIDE
P.L.
Lender's Name N[�na
O�. L�MA Ref.#
P.0 Fee S � Permit Fee '
- Lender'sAddress ;ff �q s�
I certify tha�I hove read this application and siate that the issuan<e Fee �/ LDMA PiC N -
¢ above informotion is corr t.I ogree 1 omply with all County Invesrigorion Fee ._a,�?
m ordina ces and State s relatin o building construction, To�ol Fee IDMA Perm.#
" and reby a thori represen ves of fhis County to enter ,
$ upo the ab ntioned erty for inspection purposes. ?C.-o !y��'
.3-7 �
" ,,��% ��..�n SEE REVERSE fOR EXPIANATORY LANGUAGE
E
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-�� of Appllmnf or Agen� Date . . .. ... -... . .. '. -
�: ,
PLANS TO APPL7GANT� INSPECTOR'S NOTES OR'NER-BUILDER DECI.ARATIOti "
I hereby affirm ihat I om exempi from�he Contra<tar's
To: � Ref�rned . � License Low for the following reason. (Sec 7031.SJ
Approved Businesa und Professions Code:An y creyo ur cossm{y u:l ir! '
No. Dafe No. Do}e� -� reyuiree�a permrt to ronstruct,alter,imJrrnve,demolish,
r r repasr¢ny structure,prior an[U issuunm,alrn requires
� , tbe�pj Zic¢nt,�ir sssc6 permit to fs'!e a signed stat¢ment
, tl at he is/ice»svd puesuunt to tbe provisions of!1 e Cnn-
_ . _ ,, ' � . " � � trucinr's I irense Lau(Cfiapter)J(commencing uiEh Sec-
tion 7000J o�7?lei.vinn 3 n�tfie Busine.cc«nd Professinns
- . CodeJ or thai be is exempt eherefrom a»d the fiae�i.v for tfie
ulleged e.eemplinn.Any violation nf Section 7031.5 by
Required Date Receivad � any a/pli�ani(r a permrt subjecu�tbe applicant to a ciril
Approvals or Approved , penul[y njnot mnre thux fire 1 vndred dollars/55DOJ./:
. Yes No .. . � - [] I,os owner of the property,or my employees with
Water Certificote , . wages as lheir sole compensa7ion,will do the work,and
rhe structure is not intended or offered for sale j5ec.7044)
HeaNh Deportment l3vsiness and Profesxroxs Code:The Cantractnr's License
Lau.•does not npply m an ou�ner nf property a•bo huilJs
fire Deportment .. or improres tGerenn,and u�bo does aucfi u�ork bimself ar
t!rnug5 his own emf�lnyees, pmuidcd that auch im-
Grading �� provemunts ¢re nnt intended nr ofJered for sale. -
� hnwe:�er,t/e buildlxq or rmprnnement is sold u�rthin o
Geologiml Veur of rompletinm, the numer-burlder v�ifZ hace tfie
6:erden nj prnving tbut br d'ut not build nr rmprnz•e(r
the osa� sale.
Pedestrian Profection f'u'r' f �
(Fence)(Canopy) � � I,os owner of ihe property,om ezdusively controo
fing with Iicensed�mMraclors to mnstrutl the project(Sec.
Speciol Inspection " 7044)Hu.aineas and I'r fes.rrnns Cn�le: 'Tbe Contracror's
�Conc.J(Masanry)(WeldingJ License I.aa�does nnt a/rp[y tn an numer of prnparty wLn
buildc nr imprnres ifierenn,anJ a�ho coxtracts for suc{'
Lot Drainage prr jecas wit!a rnntrucior(sJ lirenxrJ pursuunf m tl e
Cnnrractar's I.icen.ce I,rau:J. �
Porking - _, �
�_.i I am exempt under5ec. ,6.8P.C.for ihis
�� 7/' reason
O
Date Owner
Approvals Uafe �speclor's Signalure . �NSPECTOR'S NOTES
Locailon---� .
�Setback&Yards) � ~/' � 9
Poundations °
SIa6 �
Frame .,?� � /�{ . . . -
'3�
Energy Insulotion �J �
_ '�.-�.%'% . ,_
Lath/Drywo I I-�- ,.v
Interior %.�"i.q � �'Y. +.-.__../ /��� ,.
Loth. Exierior �p � �,/ n �l �;��`� . . . , ..
House Number-- . � �
CorreU&Posted
finol— —
En�er on FroM •
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