HomeMy WebLinkAbout1768A 1769A (10) WORKERS'COMPENSATION DECLARATION � �vv �� '
I hereby affirm ��a� I have a cer�ifimie o,mnsenf to se�f � � � ��-- �pp��CATION ��FO� ����UILDIIVG� PERM(T �
. insure,or a certificate of Workers'Compensation Insurance, __
or a ce�rified copy thereo4(Sec.3600,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P�cyn�aWCC253824ddlnpaoy Pac. Employers suaoiN�
Certified ropy is hereby furnished. FOR APPUCANT TO FILL IN- P.00aess ��-�'� � � -
� Cer7ified copy is filed wifh ihe cou ty 6uilding in eo- BUILDING Y ,(�
fion deparfinent. j ,... ADDRESS V, -U
/i /
Dafe �� � Appli<aM ��� arv Diamond Bar zia 91765 �ocnun
CERTIFICATE OF EXEMPTI_ FROM-WORKERS'� NO.OF BLDGS. NEAREST . . � - -
COMPENSATIOf�'/Ji�iSURANCE SIZE OF LOi NOW ON LOT —O— CROSS S7..
(This section need no1 be comrsleted if the permit is for one A55ESSOR
hundred dollars($100)or less.) TRACT O g�OCK LOT NO. MAP gOOK PAGE PARCEL
TEL. ZONE �P �7
I certify that in the performance of the work for which this �WNERM,�T. BYOCIC Y¢ SOi15 No.529-8170 ��� NO. ����J y
permit is issued,I shall not employ any person in any manner p SPECIAL a
so as to become subjecf to fhe Workers'Compensation�aws. A�DRE55 •�, BOX35Q �-l�d A L� CANDITIONS �
cirv Brea CA z�P 2621 �
Date Appli<ant ARCHITECT O . TE�� DISTRICT GROUP TVPE FlRE PROCESSED BY �
NOTICE TO APPLICANT: If, after moking lhis Certificote of �„�, Ma OY'S t� �S50 .8�J2—$17� �
F"'�.Exemption, you shoold become sublect to the Workers' En�GiNEER f Nf�,Si� ZOyE,
Compensalion provisions of the Labor Code,yo�most forfh- qDDRE55 ZOS�FI 5 P8Y'HIR011IIt Ave. Downe `v ��3 �S� �
< `.vith mmply with such provisions or this permit shall be � ' "' -"'}pt."��-��`��'" "��"� STATIS7ICA�CLASS)FI_CATION AP7. ODN00. �
deemed revoked. GONTRAC70R Owner ryp. l��> ,�, �
UCENSED CONTRACTORS DECLARAiION ���, QA55 NO. DWELL.UNITS
I here6y affirm that I am liwnsed onder provisions of Chapter 9 ADDRESS NO.
(commencing with Sedion 7000)of Division 3 of the Business ond LIG SEWER MAP �
, Professions Code,and my license is in full force and effect. CITV CLA55 BK � VALIDATION
�� � 5�.FT. NO.OF NO.OF CHECK
LiceF�se Number 54648 Lic.CIasS Bl SIZE STORIES FAMILIES ONE
� - � .- -�� � VALUAT)ON
�ESCRIPTION OF WORK ' - NEW /��� �'� �,�I ����F
� Confracfor pote . App � S E
�I om ezempf under Sec. Wltll 3ttHCtl2Cl 3rd e. A�TER � , �� � � �G�
B.&P.C.for ihis r�ason . REPAIR � S
i e48t.i1.h
;� O1e' XISi�iNG BLDG. j�r ,� DEMOL ❑ *
Signature � APPLICAM TEL. FINAI '� £��i �.�!b�
PRINT�L�I,J. Brock & Sons No.529-817D 3-.��?-�)
NER-BUILDER CLARATION DATE
I hereby aff"y`� hot I am exempf from the Confractor's License P,Q. $OX 350, Brea, CE1 92621 ' �4',��Y J�
Law for fh� ollowing reason(Section 7031.5, Business and /+�DRE55 FINAL
Professions ode): ES Ni BY
.� BUILOING . .._._ . ...._, . . �
1, as owner of the property, or my employees with ADDRESS
wages as Iheir sole compensation,will do the work ond ,� _ �
the structure is not intended or offered for sale(Section �OCALITY � �' � �t.9 A•,
"� 7044,Business and Professions Code). MOVING '� TEL , . ,�
�- CONTRACTOR NO. i' " � `� a d �
I,as owner of the property,om exclusively confraciing
wi�h licensed contrac�ors to consrroct ihe projec�(Sec- . i .,
iion 7044,Business and Professions Code). ADDRESS �� S ��C'�i
REQUIRED TOTAL SETBA K
CON57RUCTION LENDING AGENCY �� " SET BACK YARD HWY pgpp,��NE wi�iH ��n L�i �',O U c�-'
I hereby affirm ihat 7here is o construction lending agency for FRONT
ibe performance of the work for which this permit is issued P.L � (,'�(;'C�-b�
(Sec.3097,Civ.C.). SiDE
P.L.
m Lender's Name None
(� /�O Q S"0 LDMA Ref.N
P.C.Fee$ T� Permit Fee V (] ' ' .
- Lender's Address 5..��
I certify thm I have read ihis applimtion and staTe that the iss�once Fee � IDMA P/C#
y above information is correc7.I agree to<omply wiih all Coumy ���esrigarion Fee
� ordina ces and Stafe laws r ing to buil ing consiruction, _ 70�01 Fee LDMA Perm.#
and hej�by authorize e ntatives �s Couny to enter
2 upon�,./fh'e obove�ent'r d propert nspection pu�poses. /y�✓ � �
n ?��G�,�.��-�,r�/jy�� ,�/^ ' ��� 5 E REVERSE fOR EXPLANATORV LANGUAGE
f/� Signoture of plimn�or gen� Da�e - - ' ' - '����� �
� /
PLANS TO APPLICANT'' " INSPECTOR'S NOTES O49NER•BUII.DH:R DFCLARATION
. , . I hereby affirm�hoi I am exempt from ihe Contracior's
To: - Returned License Law for the following reason. �(Sec. 7031.5) �
Approved Business and Prnfessions Code:Any cie.y or county mbicfi
No. DaTe No. 'Dafe � reyurres a permit to rnnstruct,ufter,improx�e,denxnlisb,
� or repair uny strudure,firinr tr�i1s irsuuttc'e,also requires
tLe upp[icant f r su�l pern�it to frle a s{qned stutemext
, that be is lirensedpurswa»t to t1,e jirorlsions of the Con-
� ._ ^ . , � . tractorS�I.irensc Law(Cfiupter 9J(rommenring u�iafi,Sec-
tion 7000J n!!A'a�isinn 3 f tba Bwsiness and ProJassions
� Cnde/or tb�t he is e.rempt tberefrom asd the basis frir the
ulleged e.remptrnn.Any violation of Section 7031.j Fi}�
Required Date Received�� � miv afiQlic¢nt fi�r a fiermit sulrjecta 1Ge ap�[ican2 M�civif
Approvals or Approved penalt��rJ noa more thaa jive hundred do(larx(S500J.J:
Yes No
` ' " � � I,os owner of the property,or my employees wifh
Water Certificale , , wages as Iheir sale compensmion,will do the work,and
� the structure is not intended or offered for sale(Sec.7044)
Health Depariment � - � I3usiness and Prri�essinns Cnde:T/e Contracenr:v I,itense
Luu:rloea no!np]�(v to an owner of property u�fin bailJs
Fire Departmenl . or improves tbcrcow,arerl u�Gn does suc!¢�ork!iinself or
� tbrnugb his ou�n employees, proz•ided thut sur1��im-
Gradin prorements arc not intended r nffercd jnr sale. Ij,
g ir
" hnu�ex.•er,the fiur7ding or improvemext is sold within one
Geologiml -1'ear nf mmpletinn, tl e o¢�ner-bu!lder will bn�:e th�
hurden of pmri X ahat he did not 5rerfd or imprnwe f i
Pedesrc�an Prorectlon age purpoav o�saleJ.
(Fence)(Canopy) C I,as owner of the propeny,om exdusively confroo
ling-with licensed contraclors to conslruct the project(Sec.
. Special Inspection 7044�13ue�iness uxd Pmfessintts Cnde:The Contructnri
(Conc.�(MasonryJ(Welding) Limnse Lau�does nat upplp tn an ou�xer n/prnpe:ty u�bo
builds nr rvmprones therenn,ared whn comtructs fnr ruch
loi Drainoge pr j�ed� mit!u contructor(sJ licexsed Juccuunt do tbe
Contractnr'.s Li��ense I,uiu/. -
Parking ;] I am exempr under Sec ,B.&P.C.for thls
,� . .. .. ....... . _....._____.. . _ .. .. ....
� ��J �. t� .. /� reoson "
/.�,�X
� Date Owner
Approvals Dafe nspector's SignWure . �
. INSPECTOR'S NOTES
Loca�ion-- p '/
(Setback&Yards) �.` C � .
Foundations �' ��
Slab t
Frame �� �"� ��
`sLf� Y
Energy Insulatian �J���7 � r
J
Loth/Drywall-�- ,7 � ' � �
Interior �-`�"/�'� (�� �/
Lath—Exterior ^r^�!'s' ' �
_'.Z..�% l. ('- � ' -
House Number - � - �
Correct 8 Posted
Fina�-- ,. � .
Enter an Front - ' � -�