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Home My WebLink About1802A 1803A (10) � WORKERS'COMPENSATION DECLARA710N ' -� : '�aO /3 � ~ - . . . . . .... .. .. . . . .. .,. _ . . . . .. . . ... Lhereby affirm fhat I hove a certificote of consent to self APpLICATIO�V - F��R��BUILDI�N�� PERM�~i'� insure,or a certificate of Workers'Compensation Insurance, " or o certi4ied copy thereof(Sec 3$OO,lab.C.) � ��-� . . COUNTY Of LOS ANGELES BUILDING AND SAFETY PolicyNcPWCC�7�R�Lt$@]npany P�r._ F,mi1nT_ar.� � - - - - � . � Cerrfied copy is hereby furnished. FOR APPLICANT TO FILL IN BUIIDING )�Z7 � �� ADORE55 / Certified copy�s filed with-the couniy buil ing inspe BUItDING i2 tion depariment. ADDRE55 �� Date F�22 '� Applicont aTr Diamond Bar Z1P 91765 �ocaurr CERTIFICATE OF EXEMPTIO ROM RKERS' ' NO.OF BLDGS. NEAREST . . COMPENSATION I SURANCE . SIZE OF LOT NOW ON LO7 — — CRO55 57. (This section need not be completed if the permit is far one � ASSESSOR - - .hundred dollars($100)or less.) TRAC7 BLOCK LOT NO. MAp BOOK� PAGE PARCEL OWNEfNI.J. Brock & Sons N�.29-8170 USE ZONE niaP ��,3� I certity thoi in ihe performance of the work for which this �� NO. permit is issued,I sholl not employ any person in ony mpnner qODRE55P.�. �OX 35� SPECIAL - p�, �. so as to become subject to ihe Workers'Compensation Laws. .�P� CONDITIONS 0 v Oate � Applicont ��n Brea CA z�P 2`22 � � � ,�°"'°7TICE�TO APPLICANT� If, afier makin this Certifiwie of ARCHiTECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BV 0 I 9 ENGINEER L,C. Ma'ors & Asso�eo.8 2-8177 N � amption, you should become subject to the Workers' ��( CON ZONE V c:ompensation provisions�of ihe Labor Code,you must forth- qooee551OH�+1 S. Paramount Ave. Downe /� �"3 p�. with comply w�th such provisions or rhis permit shall be � � � � TE� � vf deemecl revokecl. STATISTICAL C1A551FICATION � �� APT. CON�O. Z � CONTRACTOR OWReT' NO. LICENSED CONTRACTORS DECLARATION � ��. QASS NO.��WELL.UNI75 I hereby affirm ihat I am licensed under provisions of Chapter9 A�DRE55 ND. , (commencing with Section 7000)of Division 3 of�he Business and � LIC SEWER MAP Professions Code,and my license is in full force and effect. CITY CLA55 BK � VAIIDATION � 5(].FT., NO.OF,. NO.OF CHECK License Number 54648 u�.ciass BZ SIZE STORIES FAMILIES oNe vew sin le famil NEw VAWATION Conira[tor - - Dote DESCRIPTION OF WORI� g y ❑ s ��% d,� �� L`�7„C� ADD � nt ' �I pm exempt under Sec. V1C.I1 attached garage. O ., , �*�1 ALTER B.&P.C.for ihis reason REPAIR ❑ S I 4��` I,��,�,G � Date: USE OF DEMOL EXISTING BLDG' ❑ � T Signature - APP`P IR NTTM,J. Brock & Sons No.529—c4170 �� : J 4�"',C�` FINAL ER-BUILDER DECLARATION � _. DATE r-?- Q y,�(;�3—�£}(� I hereby affirm t at I om exempt from ihe Conirocror's License P,Q. $OX 350, Brea, CA 92622 law for ihe f owing reason'(Section 7037.5, Business and AODRE55 FINA��"'y - Professions Codej: � -�� p ry By f � f^'�� BUILOING . � I, as owner of ihe properly, or my employees wifh ADDRE55 wages as their sole tompensation,will do the work and � r= I t��:�%�S ihe struUure is not intended or offered for sale(Section ��TY " 7044,Business ond Professions Code). MOVING TEL ��j;r..e a a r� � I,as owner of the propeny,om exdusively contracting CONiRaCTok NO. ' � wiih licensed contracrors to construn ihe projec�(Seo- , � `�' �'-�'G fion 7044,Business and Professions Code). ADDRESS CONSTRUCTION LEIJDIN6 AGENCV � � �7�gq�� YARO HWY TOTAP�SEOTB LCNEFR M W�DTIi � �� J i�cS.-i� I hereby affirm thai there is a constru<tion lending agency for FRONT �y.Ci�,f2 b the performance af the work for which ihis permit is issued P.L. (Sec.3097,Civ.C.). SiDE P.l. Lender's Nome �B�}e Q 6 p LDMA Ref.R - lender's Address � P.0 fee$ �. Perm�r Fee il��S� , I cenify that I have read this application and state that the issuance Fee 0' g LDMA P/C# a6ove information is correct.I agree to comply with all County Inves�i9a�ion Fee � ordinance5 and Stat laws relafing to building conslruction, 7otal Fee LDMA Perm.# - � and here y author� represe tives of this County 10 enter � upon f abo� entioned periy fo�inspeciion p�rposes. S ! Z a � �SEE REVERSE FOR E%PLANATORY LAN UAGE Signatur of Appllcant ar Agen� Da�e -- '' (i/G.� "' `- C: J PLANS TO APPLICANT � � �- INSPECTOR'S NOTES O�L'NCR-StiII,DL'R DFCLARATION I hereby affirm ihal I am exempt from�he Coniracfar's To: Returned � � � License Law for the following reason. (Sec. 7031�.�) Approved Dusiness und Professiona Gide:Any city orcoutttv wbicb No. Dofe No. � Dofe _ reyuires a permit Lo constrrecy alter,improve,deraolub, , nr rePair any structssre,prinr to.its issuance,also reyuires , , tl e appficarot for sucb[Iermit to ffle a sigxed sta[emext tl�ut hc ir licenserl pursuaxt to t5e prnaisinas oJ tAe Cnvr _ �.; . \ trador's License I,dv.�(Chupter 9J(cnmmencing u�itJ Sec- aiun 7000J oj Divrsinn 3 0/th¢Busireess uv�d Prnfessio+u . � Code/nrtAut h'e i.s exempt therejrom�and PGe,basaF/orthe ulleged exemptrn�.AnY*��Iatdon oJSe��tiun 7031.5 bp � Requirad Dafe Receiyad any applicantJnr a permra subjects tbr�applicant to a civil Approvals o�APP�OVed , yenalty of nod mnre tbnn five bundred dollors/5�00/.J: Ves No � � . -- � � - - � �' "' ' .__ I,as owner of the proper}y,or my employees with Waler Cerfificate . . wages as iheir sole compensalion,will do the work,and the structure is not intended or offered for sale(Sec.70441 Healrh Depariment . � � � Business axd Pmjessions Code:Tbe Contrattnr's I.icense La¢•dues not apply�tii an oumer rf property u.�bn buifds Pire Department � orim[�rooes tLermn,und wbn dnessuch ecnrk himselJor tGrough 5is uu�n empinyees,proi�ided thut sucl� ir� Groding pmr�ements are rsod intended ur qffered for sule. - hnu�ex�er,tfie fiur[drn,q nr improvement is sold within onv Geoloqiml . 1'ear oj conrpletion, t!e owser-buildar u�ill hr�x�e t!e bumten�f provin,�+lbaf h�Jirl no1 burld nr improve for Pedestrion Protection " lhe purpose nJ saleJ. (fence)(Canopy) �] I,os owner of rhe properly,om exdusively coniroc- iing with Ilcensed conlracrors to mnstruct the projec!(Sec. Speciol Inspection .. 7044)Busine.s.c and Prnfersions CoJe: Tbe Cnntru<�iur:c (Conc)(Masonry)(Welding) � l,icen.ee I.am dnes not appl}�to un ou�xar<f prnpertv u�l o builJs ar improve.c tberenn,and a•bn cnntracts f r sarh Lo�Droinoge � � � � /�rojects u�ith a cnmtrac.tor(vJ licensed/�unwaat En tGe Cnntra��tor's L.immse LawJ. Parking ❑ I om exempt under Sec. ,6.8P.C.for rhis .,� � � / � � - � reason�.. - f'1.0� !'?-q'Yi._ f /'� . . , ' _ / °y'` Dafe � Owner Approvals Date Inspecfor's Signaf�e . . . ._ INSPECTOR'S NOTES Location— � 1 r {Setback 8 Yards? / � Foundations G- �/ � �� Slab ',�/ /,r' � . .� . � � Fiame �� , �� Energy Insulotion rj��_�' (?/,7 � � - � � � . . L �� ' Lath/Orywall— r�r�y� � � - � .• . .... ., ._.. . . .. . . -. Inlerior t d Lalh—Exterio� � � House Number— - �' � ' ' � � � � � CorreU 8 Posted � Final-- . � . .. � .. .. . .. . � ,,.. Enter on Front � � "'�-� - "