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Home My WebLink About1776A 1777A 4':�'ORKERS'COMPENSATION DECLARATION �O v �� , I hereby�affirm that I have a certifiwte ot consent fo se�f APPLICATION FOR �BUILDING-��PE1�IVIIT � �-�� insore,or o certificate of Workers'Compensa7ion Insuronce, or a certified copy thereof(Sea 380D;La6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �cyrd�bJCC253824d�1npany Pac. Em��oygr.� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN eu��o��vc �� j()��h�� ,�/,� � ADDRESS vy' (!' Certified<opy is filed with the coumy�building ins o- gURDiNG Q C tion department. ADDRE55 ('.J �,] L�(] �.,�, Dare �-2��,pplimnt k/ ciTv Diamond Bar ZiP 91765 LOCALITY � CERTIFICATE OF EXEMPTIO F OM WORKE ' NO.OF BLDGS. � NEAREST . COMPENSATION I RANCE SIZE OF LO7 NOW ON LOi —Q— CRO55 ST. (This secfion need not be completed if the permit is for ane TRACT S BLOCK LOT NO. ! ASSESSOR ' - hundred dallars($100)or less.) MkP 800K PAGE PARCEI TEL � owNeRK.J. Brock 8 Sons No524-8ll0 us NE nnac l��y I certify ihat in ihe performance of the work tor which this ��.jj NO. y permit is issued,�shall noi employ any person in any manner p SPECIAL - � -- d so as to become subjecl fo fhe Workers'Compensafion Laws. ADDRE55 .�. BOX 3J� � /JC C} CONDItIONS � 6.7 Date Applicanf . CI7V Br. A ziP 2j �¢c ARCHITECT O TEL � NOTICE TO APPLICANT: If, aker making this Cer�ificate of � �ISTRICT GROUP NPE FIRE PROCESSED BY r"`^ � ENGINEER ,Ci. 1"t$ Or5 & Assoavo.862-8177 .,,°�� kxemption, you should become subject to the Workers' C zOnle y Compensotion provisions of the Labor Code,you must torth- �� W ADDRESS IO �V1 S P m unt Ave D can j d -3 d with comply with such provisions or ihis permit shall be - - - - tEL � y deemed revoked. STATISTICAL CL4SSIFICATION APT. CONDO. � CONTRACTOR QLdI12Y NO. LICENSED CONTRACTORS DECLARATION ��_ CLASS NO.�DWELL.UNITS I hereby affirm that I am licensed under provisions of Chapler 9 ADDRE55 NO- (commencing wiih Section 7000)of Division 3 of fhe Business and �� SEWER MAP Professions Code,and my license is in fu�l force and effect CITY C1A55 BK � VALIDATION 5�.FT. NO.OF NO.OF CHECK License Numher 54648 tic.Closs U1 S�ze STORIES Fqnn�uEs oNe . . g ALU/�T�U'� �!,�o u o G F. COnfIaCtOr Dat2 � DESCRIPiIONOPWORK�2W S1R le IBIRll NEW � ` ;� � ADD � �1 am exempt��de�se�. � with attached ara 2. q�7ER ❑ � ^E::i,�J.] 8.&P.C.for this reason � § REPAIR S USE OF " ..v 1 F��U " EXISTING BLDG. I�� A �EMOL ❑ - Signafure Ct APPLICANT TEL. &j�/.Cj�—�� OTWf�IER-BUIIDER DECL ATION PRINT)]�'1 J Br ck & Sons No52 —817 pA E��`i,-�t�"�/ , , I here6y offirm it�f I am exempt from ihe ConiroCfor's License qDDRE55 P.�. BOX 350, Brea,CE� 92621 Low for the follo�ving reason(Section 7031.5, Business and FINAL- ' Professions Code): PRESENT gY '" � BUILDING . . ' I, as owner of the property, or my employees with ADDRE55 % � ��:�A , wages as their sole compensation,wJl do the work and the structore is not iMended or offered tar sale(Secfion LOCA�ITY , , , �s, �t e, e � � 7044,Business and Professions Code). MOVING TEL. I,as owner of 1he property,am exclosively coniracfing CONTRAC70R NO. � d-,j 7��_i�O � with licensed contractors to consiroct ihe project(Sec- qDDRE55 �� T iion 70d4,Business and Professions Code). s �' / '](j U` CONSTRUC710N LENDING AGENCY �� bET�BACK yARD HWY T�TApROP.�LINEFROM yyIDTH c I hereby affirm that there is a construcfion lending agency for FRDnIT i��%:C�'—�6 the performance of the work for which�his permit is issued P.L. � (Sec.3097,Civ.C.). SIDE P.l. Lender's Name None ��J, . :.,J I rJ $' S"'� IDMA Ref.# J P.G Fee$ S ' Permit Fee ' - Lender's Address s� I certify tha�I have read this application and state ihat the issuonce Fee Q LDMA P/C# - above information is correct.I agree to comply wilh all County Investiga�ion Fee +_y��C 3 ordinances and$tale Ipws reloting to building consiruciion, Total Fee U LDMA Perm.# " and ereby authorize r presenta' es of ihis County to enter � upo ihe above e ned pr for inspection purposes. ' � �C-e�0 �5 qp�,7, Js)j - TJ . , . . . . (/ G� �'�h SEE REVERSE FOR EXPLANA70RY LANGUAGE Signar�re of plicant orAgenr pore - - . - - -.. ,7'7"f y� . . :)'. f / PLANS TO APPLICANT ' INSPECTOR'S NOTES O441EH-BUILDER D3iCI.ARATIO\ � _ _ I hereby affirm ihat I am exempt from Iha�Comractar's To: � Raturned License Law for the following reason. (Sec 7031.5J Approved $usiness anJ Pmfcaaions Code:Any city or country which No. Date No. Dafe reguiras a/�ernelt to construrt,alter,im�rove,llemolrsh, . ��or repuir any structure,prior to its usursnce,u/so requtres , the applicani fnr suc{�pernrit ta jile a signed stutcn:enl , , . that he rs licensedpursua�at to the prox�isinns of 15e Con- ' . � " = � �. •�� tructor's I.irense f.au�(Cbapter 9/lcnmmenreng u�iEb.Sec- . ". .:..- � .� ....... ^: . �` . tioxi 70U0/nj Uia�ision 3 nf tbe➢usiness und Professsons �CodeJ ai tbat he rs exempt tber from,a+�d the�haci.��for tGe . u!le,qed exemptinn.An,y violatiox of Section 7031.5 ly Required Date Reeeired any¢pplirantf�ra pernrit subjects Lbe aJiJili�unt to a cixv! Approvals or Approved penalty of�oE more ihax five hundreJ�lollars(8500/./: Yes No • . , . - � ❑ I,as owner of ihe property,or my employees with Wa;er Certificare . . � woqes as ihelr sole compensation,will do the work,and �he structure is not intended or offered for sale(Sec.7044) Health Deparfinenl - � � � ,� � Ifusiness¢nd Professinns Corle:Tbe Contruator'.c Licrnse Luu•dves nnt apj�lq�tn an owner qj prnperty mfin buildr Fire DepartmeM .. or improves tberenn,and whn doea suc]work 1 imsel�or , through hic ou�n empinyees, pro:�ided tbud sucb im- Grading '- provemenh are not intended or ofJered for sale. If. � , , Fir u�erer,tGe hu!lding or improve»aent is snl�l uitbin nne. Geological vear of mmp[etron, the au:nar-lsuilder ud!!hano tbe � burden of proning tbaa 6e drd nnt build or rmprore for Pedestrian Protection. . � � tbe pu pn.ee of saleJ. fFence)(Canopy} � I,os owner of the property,am exduslvely mnhao ting with licensed contro<brs lo construct 1he project�Sec. . Speual Inspection 7044)Business and Prnfesrinxs Code: 'Tbc Contractor's (Conc)(Masonry)(Weldingl l.irense Law doe.e nnt upply tn An nirner of fir�rertY��bo builds or imprnves tberen�,and wbn co�atracts jor sucl Lot Drainage project.�� u�1t1 a ronerucenr/s/ licensed pursuunt tn the CnntracEnr's Liccasc I.¢w/. Parking �, I om exempl under Sec ,B.BP.C.for ihis �j �/ . �y �-� ..O-.• � -... reason � !) zx C s � Date� Owner Approvals �afe inspeoTor's Signature . . . - f INSPECTOR'S NOTES Loca��on-�- - ' (Sethack 8 Yards) / f i �. Foondations . Slab ,�,,...—•�'^..,�— Frame jr�G_�� Energy Insulation , �3 •7 ') J�,/ . _ T -ti Lath/Drywall-- ` � � �� Imerior _�% .'� � ��y.y+---'�� Lath.-Exterior �",i._�� ;Y��,�..�� Z . House Number-- - '� ' � -- � Correct 8 Posted Final-- � � - � Enfer on Front � �