HomeMy WebLinkAbout1794A 1795A , -.�JJORKERS'COMPENSATION 6ECLARATION � � •
soo 131� -
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.I hereby a4firm ihai I have a certificote of mnsem to self app��C�ATIOtV FOR- BU�ILDING PERMIT ��
insore,or a certificote of Workers'Compensation lnsurance,
' or a certified copy thereof�Sec:3800.La6.C.) . -..-.- - . . ...--_.__.__....._._.__. ..... ,,...,,r...: ..,. , ....
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- COUNTY OF LOS ANGELES BUILDING:AND.SAFETY
�<yNal'WCC253824dd�mpa�yPar_ F,mz 1n�er� - . . -. - ._.. _
BUILDING �p
Ce�rifed�opy is hereby 4u���shed. FOR APPLICANT TO FILL IN nooeess ���-(� � .�Y.Q-yy 0��
� Ceriified copy'is filed with ihe county buildi g inspe BUILDiNG � �� � � (�
��on department. ADDRE55 _
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Dote Appliconi arv Diamond Bar ziP 1765 LOCALITY
CERTIfICATE OF EXEMPTION F M W KERS' ' NO.OF BLDGS. - ' ' NEARESi . . .- . - .
� COMPENSATION INS ANCE S¢E OF LOT NOW ON lOT -O- CROSS ST.
(This section need noi be completed i4 the permit is for one TRACt BLOCK LOT NO. ASSESSOR � - ' .
hundred dollars(5100)or less.) _ M1�P�K PAGE PARCEL�
�� U Z,ONE �+P `
I certify that in the performance of the work for which ihis OWNER[�f,J. Brock & Sons No.529-8170 ��� Np. L'�3� }
permii is issued,I shall not emplay any person in any manner ���� SPECIAL � ' �- -� � - - �
so as to become subject to the Workers'Compensotioh Laws. ADDRESSP.�, BOX 350 Brea, CE1 9....I_- �/f0 I.t CONDITIONS �
u
Date ' Applicant CITY . ZIP �
NOTICE TO APPLICANT: If, affer makin this Certifi<ate of ARCHITECTOR TE�� DISTRICT GROUP ttPE FIRE PROCESSE�BV �
`�Exemplion,'ypu should 6etome Subjec� to fhe Workers' ENGINEER �.C, Ma'ors C4c .�iSSOIHn. - CON�$TI ZONE v
� � Compensotion pro isions of the La6or Code,you must forth- I,/� ��.� �
v
ADDRESS1OH�41 S. Paramount Ave. Downe � �
with comply with such provisions or ihis permit shali be � �� � .--- -�-���-� �- � � � �. ' �N
deemed revoked. TE�� SiATiSTICAL CIASSiFiCATION APT. CON00.
CONTRACTOR Owner NO. ,q,,,� —
LICENSED CONTRACTORS�ECLARATION - ���_ �-� CLnSS NO. �<✓ DWELL.UNI7S��
I hereby affirm thot I om licensed under provisions of Chapler 9 AD�RESS NO. SEWER MAP '
(commencing with Section 7000)of Division 3 of ihe Busines@and . ii�
Professions Code,and my license is in full force and effec�. C17V C�a55 gK � � VAIiDAT10N
SQ.FT. NO.OF NO.OF CHECK
License N�mber 54Ei4H u�.Ga:s Bl � s¢e � sroRies Fnrniues - oNe ..
- .. ' . �..• VALUATION
- �ESCRIPTION OF WORKIVEW SlIl le f3[Rll NEW s `�� `_\
CoMractor Date ., . ADD � ! rr�•� , < �r p
❑�am ezempt u�de�Sec. With 3ttaChed araoe, ' " �'�`
ALTER � a o� ¢G,�
8.&P.C.for ihis rea on REPAIR � ; T
� �ai EX STNG BIDG. ;d�A DEMOL ❑ I z�':v I.G�
Signature APPLICANT � TEL FINAI � . (; : -r
O NER-BUI ER DECLARATION PRIN7 ,T Y (� S n NO. 2. - 7 " "="r= �� •��'
_ ..... ._-.._._..._......... DA7�-� �
I hereby affirm t ot I om exempt from the Controctor's License qDDRESS D.�. Box-35� Brea Ct'� 92621 FIN �0�`•U:'�`���
Law for ihe following reason(Section 7031.5, Business and �
Professions Code): ' PRE EN ' " sY�Y
__['� , BUILDING . ,
..J" �� I, as owner of the property, or my employees wrth ADDRE55 . ... .. ..._. . .... ,. . ..__'__ .__. .
•`�' wages as their sole compensotion,will do ihe work and �� � - �
ihe sirocture is not iNended or offered for sale(Section �OCAIiN �
7044,Business ond Professions Code). MOViNG � �� 7EL � ' � , � � 'r Q,�j�
� I,qs owner of the property,om exclusively controcting CONTRACTOR NO. '
with licensed confraciOrs to constru[t'the projec�(Ser " qDDRE55 �``� ` a ' �
tion 7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY �- RE�UIRE� - TOTAL SETBACK fR0 Xi
SET BACK �ARD HWY PROP.IINE WIDTH � �� I �.U C
1 hereby affirm thot there is a construction lending ogency for PRONT �
the performance ot fhe work for which this permit is issued p.L "=%'�; `(,�(1�
(Sec.3097,Civ.C.). SIDE
a.L W`�.C�i'c C.^.
Lender's Name 1Tnne /�(�
P.C.Fee 5 , • Perm�r Fee �L l["S'S� ��'�Ref.#
Lender's Address b� ,
I certi4y that I have reod this application and state ihat 1he Issuance Fee Q L�MA P/C 8
above informotion is correct.I ogree to comply wiih oll County In�esiiga�ion Fee
ordinances qnd State lows relating fo building consfructio�, Totol fee LDMA Perm.N - �
ond hereby authorize�epresentaiives of this County ta enter •
upon ih above-rpe lroned prope farinspection porposes. �� �O ' ' �
�6 SEE REVERSE FOR EXPIANAYORY LANGUAGE
Signoture f Applican�or Agem Date . . . . . . n�
/
PLANS TO APPLICANT � � INSPECTOR'S NO7E5 n�''-�'�'-H-BUII.DER DFCLARATION
I hereby affirm ihat I am exempt from Ihe��ntracro�s
To: Returned . License Low for the following reason. (Sec 7031.Sj
Approved ��Bua�ines.c amd Pro/ussinns Code:Any city nr coundy whicl�
No. Date Na. Da}e . reyuires u/�ermrt to cnr+a�truct,alter,impmve,demoliaLr.
� "o'r'r"epair any rtructure,prror to its rssuanre,also requeres
- tbc pplic¢nl fnr sueb pernxit tn f:'fe a segneJ s2atemeni
,that he is licenserl pursunnt to the proe;rsinns oj tbe Con-
� ! . � � ' �• trrertors License I,au•(Chapter 9)(qommencing u�itb Sec-
- �tion 7000J oj Divd.eron 3 0(tFie Businers anrd Profcsxinns
C'nde/or tbat he�i;exempt therefrom and tbe birsis f x tbe
a1lgPed eKemptiore.Awrol'�rnlatinx of Sectdnn 7D31.5 by
Required Dofe Reeelved anN af�/�licant for a permi(subjeces tbe appficunr rn a ciril
Approvals or Approved � . � pena!{N of aot mnre tl an five buxdred rdnllsra(SSUOI.J:
Yes No � � . , ._ .
� � � � � ;� I,as owner of the propeny,or my employees wiih
Water Cer�ificate . , wages as iheir sole compensation,will do ihe work,and
the siructure is nol intended or offered for sale(Sec.70441
Heahh Depar�ment � • Qusiness and Prn/essinn.s Coale:The Conlracfnr:s I.icexse
l,ae��does not�p[y tn an ouner af pr�erty u�hn 5uild��
Fire Departmeni - � .. . nr in�(�mves lhereox,and¢�bo dnes sucG wnrk brmself or
ShrougG his omn evrrpinyces, jrrovided tbat suo6 im-
Groding - . � provrneents are not intenderd nr nfJercd Jor sale. If �
. - bnu•ex•er,the bmildin,P nr rm(�rnve»aent rs sold u�ft.hin on� �
Geologi<al � , � vear nf rmnpletion, tAc nuner-builder wi17 har.e tbe
burJen r f prorinq tl ut he drd nnt huild nr imprnve for
tfie purpn'se nf sale/.
Pedes�ripn Protecfiop ❑ I,os owner of rhe o ert am exdusivel contror
(Fance)(Canopy) �fing Cvith llcensed coriiroc�tors��ro consrrucl the pr ject�Sec.
Speclal Inspeclion � ' 7044)Nusiness and I'rn/essinns C�de: Tbe Cnniractor's
(Conc.)(Masonry)(Welding� � l,icense Law dnes nnt apply fn ax nu•ner of prnperty ud�n
- builds nr rn:prov�as t1 ereon,and u.�l o rontrarts for srech
Lot Drainage hr jerts wit6 u ronfractnr/�J licersred(�ursuaxL to !be
Contrurtar'.s Li��ensc l.au�J.
Parking ` " �- �
j� ❑ I am exempt under Sec. .B.BP.C.for this
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�� .:��y � rj / � reason
`��:�.Y���?'��- ,-r�z'' � �`.T.-"� . .
� - - - - � Dote � Owne�
Approrols Date Inspeclor's SI uture
. INSPECTOR'S NOTES �
Lom�ion--�
(Setback 8 Yords) ! .
Fo�ndations � � �/. � �. � , � , � - . �
Slab � t /i� _ _ _ .
i._
'� .' ... , . .
Frame _�� ��'
� r�
_ , •- .' . ..... .. -....
Energy Insulation "��, - j/2-�� � � -
C;
Loth/Drywall..... � �I ' � �
Interior /�� /
Lath—Exterior y - -
House Number- ' � � - - � �
Correct 8 Posted -
Finol... .:� ., ...�._.. - ... . � . . .
En1er on Fronf � • � �� �