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Home My WebLink About1774A 1775A (10) . _ _ _.. . .. . .. . WORKERS'COMPENSATION DECLARATION ' � � '�UQ �`� ,� � - � � . ....<.. .. .. . . ._ . . ..._ . , I hereby affirm thot I hove a certifimte af cansent to 5e�f - APP��CATTON FOR� BUILD�IN��G� PERMIT� � insure,or a certificpte of Workers'Compensotion Insurance, or a te�rified copy thereof(Sec 3800,'lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � Pno'Iicy N8[JCC253824�Ampany Pac_ T'mglc>yP_r� Certlfied copy is hereby fumrshed. FOR APPLICANT TO FILL IN BUILDING �j /��_ AD�RESS IK.aZ.� ¢�- �.Q��hA-.J (( � -Certified ropy is filed with the county building in eo- gUaoinlG tion department. AD�RE55 �� j oore "ZZ' Applicant ln/ arv Diamond Bar Z,P 91765 LOCALITY CERTIFICATE OF EXEMPTIO OM VJORKE ' NO.OF 8L�G5. NEAREST COMPENSATION I URANCE SIZE OF LOT NOW ON lOT —�— CR0.55 57. (This section need not be completed if ihe permit is for one /+� ASSESSOR � .hundred dollars($100)or less.) TRACT v BLOCK LOT NO. Mqp BpOK PAGE PARCEL TE�' USE ZONE MAP , ^),,� owNeR M.J. Brock & Sons No529-8174 d i rertify that in ihe performance of the work for which ihis �� NO. �y � permif is iss�ed,I shall not employ any person in ony monner qDDRE55 P.Q, BOX 350 ry_ SPECIAL a, so as to become subjed fo the Workers'Compensafion Laws. a.!!Od'c� CONDITIONS o V Date � Applicant - QTY ZIP � ' � ARCHITECT OR , TEL. NOTICE TO APPLICANT: If, offe� mokin this Certificate of DISTRICT GROUP NPE FIRE PROCESSED 8Y � 'P�Exemption, you sho�id t�ecome su6jecl ro �ne Workers' ENGINEER L.C. Ma ors & Asso�o. 862-8177 coNs� �e U Compensarion provisions of ihe Labor Code,you must forth- � �_ w wifh comply with such provisions or this permit shall be �+DDRE55].�H�LI S. Paramount f�V2. Downe- O. TEL STAT�STICA�CLASSIFICATION APT. CONDO. y daemed revoked. COMTRACTOR Owner Np. � LICENSED CONTRAC'TORS DECLARATION � i��. C�aSS rvo. � DWELL UNITS� I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE55 NO. (commencinq with Section 70D0)of Di'vision 3 of the Business and �� SEWER MAP Professions Code,and my license is�in full�force and effect. CITV CL.455 BK � VALIDATION SQ.FT. NO.OF NO.OF CHECK LiCenSeNumber S�h�iR Lit.Closs�� $IZE STORIES FAMILIES Oh'E - DESCRIPTION OF WOR1�2W SinPle Famil NEW � VALUATI�N ;:I h�� Gantractor ��e � ADD � S �" � � ' �:p a 9 a�� ❑I am ezempt under Sec. w1tY1 attBChed ara e. ❑ ALTER B.&P.C.for this reason _ REPAIR ; � G L'��b'`�� e: lJSE OF � DEMOL .. . . 3�c:�� ' z. E%ISTING BLDG. I� A w a�.7�- Signature APPLICANT TEL. FINAL ,A NER-BUILDER DEC RATION PRMT) N � — DATE ,�`�j -�%'' �'��'�`�6 1 here6y offir hat I am exempf from the CoMrac�or's License qODRE55p.�. BOX 350 Brea C�i 92521 � Law for ihe following reason(Section 7031.5,Business and FINAL�. ' Professions Code): " � - PRE ENT By � BUILDING ,,,�-� I, as owner of ihe property, or my employees with ADDRESS - �- � ^ wages as�heir sole compensation,will da�he work and � � " ihe structure is not intended or offered for sale(Section LOCnLiTY � � 7044,Bosiness and Professions Code). MOVING - TEL . � - :�i�Y - CONTRACTOR NO. Y 3 O I,os owner of the property,am exdusively<oMraUing - wifh licensed contractors to construct the project(Seo- ADDRE55 ;p'� �� { tion 7044,Bosiness and Professions Code). � ^ CONSTRUCTION LENOING AGENCY � SET�eAC� YARD HWV 7�T'4pROP.A NEF M WiD7H � ��!%��O O I hereby affirm ihat ihere is a construcrion lending agency for FgpNt ihe performance of the work for which this permit is issued p,L . ., „'�''��C`` (Sec 3097,Civ.C.). SIDE a .. .. .. . . ... . P.L .. Lender's Name �Tnne ��4�L�`�'�� - Le�ders Add�ess �P.c.Fee E `'.��'�� Permir Fee 6,S LDNW Ref.N , I cerlify ihat I have read ihis application and slate ihat the - Issuance Fee Q s� LDMA P/C R above information is comect.I ogree to comply with all Counry �esiiga�ion Fee a ordinances and Srare laws relating to building construclion, Total Fee- LDMA Perm.# and hereby authorize re sentatives this County to enier Qupo e above- e ' ed propert orinspecfion purposes. ��O �� b SEE REYERSE FOR EXPLANATORV LANGUAGE Siqnature of pplimnt or Agenf pa�a ��2' � � PLANS TO APPLICANT � - � INSPECTOR'S NOTES 0�4'NlR-�liILDFR DECT.ARATIOV . . _ ,_ I hereby afflrm ihat I am exempt from ihe Contractor's To: � Relurned � License Law for the following reason. (Sec. 7031.5) Approved (3xsinea.r and Professions Code:Any citv or county tc.hicfi No. �a}e No. DuTe rayuires a pernxit to mnstruct,adter,rmprnve,demndisfi, . ,. . „ .. .._..or rcpair any seructure,prior to its is.eaanrc,ulao regaires the applicunt fnr sucb permit ta fiJe a signeJ stntement tbat he u Tirensed pursuant to tfie pmvisrons f tbe Cnrr -, �� - • ' . tru�tur's 1{carzxe Lau(Chapter 9J(commencim,S wJth Sec- ._. tion 7000J rf Ui�tision 3 oj the Busiree§s und Profas.rinns ._ ._CnJeJ d'r.tbaa F,e•u.ar�mpa tberefrom and't1 e bases for t5e a!legetl,exemptlon.An.rey itinlution�f Section 7031.5 by Required Date Received any applicant f ra f�earmit snbjacGr tbo applicanx ta a ciniT Approvals or Approved penulty oj not mora tban five bundred doflars(SSOOJ.J: Yes No -� -" � � �� : I,os owner of the properry,or my employees with Woter Cenifimie � . � � � wages as their sale mmpensotion,will do ihe work,and ihe slructure is not intended or offered for sale(Sec 704G) Health Deparimen7 �� Busixess an�t Pr fessions Cnde:Tbe Cnntrartor'.c License Lum•does nnt upply to an nu�ner of/�rofierh�u�bo buildc Fire Deparrment . ..... or rmprones tfiereon,and wha does such u�ork hrmsefJor . tF.�rougG his ou�n empinyees, procided thal such im- Grading provements ure not intended or qffered for sule. If. hnu�eaer,tbe burlJin,�nr improaeraent rssnld witbin nne Geological - year r�cormpletian, tbe owner-builder ¢�ill ha::e the burJcm ajpraving tlat he did no1 burld ar empmi•e f r Pedestrion Protection tf e purpnse oJ saleJ. (Fence)(Canapy) ❑ I,as owner of Ihe property,am exdusively mnirao �ing with licensed contrpctors to mnstruct the project(Sec. Spedol Inspection - 7044)Businexa and Prn�essions Coder Tiie ContracMr's (Conc.)(Masonry)(Welding) LicenseLau•rinesnot¢rplytnannu�ner�proQertyu�ln fiuilda�nr s»eprowes thcrenn,and acbn cnntructs f r necl Lot Drainage _ - � . ..� pmject.v u�itlr a corzlracLor(SJ lirense�E rttr.vu¢nl to tbe Coretrac[ar i Z.Irense I.au�). Parking - . - . . , . � 1 om exempt under Sec. ,B.&P.C.for thls �� , ' reason � Date� Owner Approvols Dote Inspac}or' Signa}ure , . INSPECTOR'S NOTES �o�a�,o� �, `�� !Set6ack 8 Yards`l � � . Foundatlons ��.� � � Slab � � . . . . .- ' j . Frame �,,�)A.�f r ;� ��,j'.. . . . . .. .. � . ., , Energy Insulatian , '1 ^+( .S � . .. .. -•. . .� - . . } - Lmh/Drywall- j �,rj� (L'f��..�..� .. . . . ..._.. . . . . . , Interior d - Lath--Exterlor � . � House Number - , ' '� -- --� � � �--� � . � . Correct&Posted - Final- � � ,. . .. . � Enier on Front ' � �