HomeMy WebLinkAbout1800A 1801A (10) � WORKERS'COMPENSATION�DECLARATION S�� � �j�{
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I.hereby affirm that I have a cerNficale of conseM 1a self qpp�����CATI�ON FOR� �U�L�I��G-��P�RIVI�IT�
inwre,or a certificaie of Workers'Compensation Insorance,
� ora certified�copy thereof(Sec.3800,Lab.C.) � " - �"�- - � . ___._ . ... . . ...___
PolkyNoPt'�r�'.75?R7L�C3¢]npony Par Fm�l p�rc COUNTY OF LOS ANGELES BUILDING i4ND SAFETY
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� Cerfifled wpy is he�eby turnished. FOR APPLICANT TO FILL IN eu�to�Nc, /�
� ADDRESS _ p�jy�.� P�.�..�,p,f .
�. Certified copy�is filed with ihe county buildi inspec- gUaDING (�
fion deparfinent. AODRE55 � � k.J �j
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Dafe rrZ2� AppliCant uTr Diamond Bar ZIP 91765 LOCAIITY
CERTIFICATE OF EXEMPTION M W ERS' � NO.OF BlDGS. - NEAREST . _. . .
COMPENSATION IN RANCE SIZE OF LOT NOW ON LDi —O— CROSS ST.
(This section need no�be completed if�he permit is for one G /� ASSESSOR
hundred doilars�$100)or�ess.) TRACT J BLOCK LOT NO. t�J /�p,p gpOK PAGE PARCEL
owNeRM.J. Brock & Sons No.529-8170 use otie �nnP `� ��p
I certify that in the performance of the work for wh�ich�his �'��! Na� / �.
permit is issued,I shall npf employ any person in any manner qDDRESS P Q. BOX 35� s� SPECIAL �
so as to become subject to the Workers'Compensation Laws. .L.Z� p CONDITIONS O
arr Brea CA ziP92621 �
Oafe Applicant .. . . �
" .,�"�7TICE TO APPLIG4NT: If, afrer making this'Certificate of .4RCNITECTOR TEL O
DISTRICT GROLIP TVPE fIRE PROCESSE�8V
:mption, you should become subject to the Workers' ENGINEER O. — ^ CON ZONE V
�ompensation provisions of ihe La6or Code,you must forth- �v I�-''j
no�aEs�.0841 S. Paramount Ave. Downe � a
with comply wiih s�ch provisions or ihis permi7 shall be � 7EL. y
deemed revoked. S7ATIS7ICAL CtA551FICATION AM. CANDO.� �
coNrancroR Owner No. �
LICENSED CONTRACTORS�ECLARATION ii�. CiASS NO. � DWELI.UNITS�
I hereby affirm ihai I am licensed�nder provisians of Chqpler 9 AODRE55 NO. SEWER MAP
(commencing with Section 7000)of Divi9ion 3 of ihe Business and ��C.
Professions Code,and my litense is in full for<a and effecr. CITY Cw55 gK � VA�IDATION
$Q.FT. NO-OF NO.OF CHECK
license Numbe� 54h4£3 Lic.Class R� SIZE STORIES FAMiLIES ONE
o V9IWATION �;l, C v'.�a
COMrqCtor Date DESCRIPTIONOFWORKIVEW 51Ra12 f8I1111 NEW ❑ /�� �
ADD � s � � r, <° � d l�
�I om exempt under Sec. Wltfl 8tt3CY1.2C1 ara 2. q�TER �
eCl� i.:1S
B.BP.C.for ihis r pson REPAIR � $
USE OF DEMOL ❑ "P�'i� �•O 1' .
Dafe: ExISTING BLDG. [� � U�'
$ignature APPLPR M � N L. FINAL f [/ C��.G�"t`i� �
NER-BUIL ER DECLARAT�ON � — DATE �` � ��
I hereby affi� ihat I am exempt from the Contracfor's License /f
Law for the ollowing reoson (Section 7037.5, Business ond aoDRESS p�ryq �J/-r"'v �.
Professions Code): pR By
C�
�`"`"`� I, as owner of fhe property, or my employees with qDDRESS
' waqes as their sole<ompensotion,will do ihe work�and �OCALiTY , `. . =� � �'U��'�
the strucfure is not intended or affered far sole(Secrion •
7044,Bosiness and Professions Code). MOVING � TEL. � _ - �
� CONTRACTOk NO. ^� " e ° �Y I
I,as owner of fhe property,pm exclusively controcfing ``
wi�h licensed contrac�ors to tonstruct ihe project(Sec- qDORE55 t °�;i %.C�i
tion 7044,Business and Prafessions Code). �
COtJSTRULTION LEIVDIfVG��P.GENCY - REOUIRED yqRD HWV TOTAL SETBACK F M XI T. r.
SEf BACK PROP.LINE WIDTH �. � :�U U� ,
1 hereby affirm lhot there is a consfruction lending agency for FRONT
the performance of the,work for which this permit is issued P.L ��,+.{j�•-Q,�
(Sec.3097,Civ.C.). SIDE
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Lender's Name1QORE
7 Q ,.4 6b LDMA Ref.#
- Lender'sAddress � -- P.C.FeeS �O Pe.mnFee 8ag' '
I certi4 ihat I have read this o licotion ond state that the 5� �
Y PP ��� iss�a.,�e Fee � mnnn aie k
above information is arrect.I agree to comply wifh all County Investigv�ion Fee �p
ordinances and Stat� ows relating ro building mnstruction, Tmal Fee tDMq perm.#
and her by author' representatives of this Couniy ta enter
o upon e - enfioned prop for inspecYion purposes. i✓^� q c-'. . - - . - - ---,
` ��� J JJ
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SEE REVERSE FOR El(PLANATORY LANGUAGE
� _ O�
� Sig re of Applicant or Agent Date . .. .. .. ___. .._. .,.. _.... _......_ � __ . _ _ . ,-
PLANS TO APPLICANT INSPECTOR'S NOTES O6�'NFR-BL'ILDER DLCLARATIOK
, „ ... .,,,,... _ _ I hereby affirm that I am exemp7 from ihe Contracfor's
To: Ret�rned License Low for the following reason. (Sec. �031.5!
Approved IIusrne�a and Pmjesstons Code:AnN city or county u.�GicG
No. Dofe No. Dofe rcyuires¢perrnif tn cunstnact,aher,improne,demolial,
. . ....._.._......._,._.,....._.,.,..�. . or rcp¢ir uny�s[ruedure,prior to iu issuanre,ala�o reyuirus
- tbe upplicund Jbr such Qermit to file a signed statement
. , ., tbut!?q is licensed pur.ruant to t!e proe�i.aions oJ tl e Ca�-
_ , . . . � tructnr'r License 1,au.�(Cbupter 9J(rommvncing wit5 Ser-
:, tinn 7000J oJ Uii�ision 3 0�ai,��8�..��fness anJ ProJessions
�CodeJ nr that 1 e is exempt 16erefrom and tl e bksis f�r the
. . ulleged exemp[don.Any urnlatiam of Section 70915 b��
Raquired Dale Reeeived any upPlirunt frm a permil subjects tbe upplicunt tn a crx�il
Approvals Yes No or Approved . . ./�enultY nf nnl mnre thmn five 1 wndred�lollors(SSOOJ./:
` ' - � ❑ I,os owner of the property,or my employees with
Waier Certificate � � � � � . wages as their sole compensation,will do ihe work,and
the structure is not intended or offered far sal,e(Sec 7044)
Healih Depariment - Business and Prnf asinRs Code:Tbe Cnretractor:��Licvnse
L¢u•does not apply to v�ov�ner nf proparty wbo builds
Fire Department or improtres tl�ereon,and wl�o does sucl�u�ork binrselJor
, tlroaagb Gis ou�n emplol�ee,v,�provided t/�at such !�-
Groding � .:prnx:ements are nnt intexded or ffered for sule. �
- hou�enrr,the hurldinq.nr inprnvement is sold+uithin or..
Geological . year nj mmpletinn, ahe ou�xer-builder uill baoe the
burden qf/rmvrn,�that bc drd nnt fiui1J nr impmve jnr
Pedestrian Protection � tl e purpose f sule/. .
(Fence)(Canopy) L� I,as owner of�he property,am exdusively mntrar
�ing with licensed mntractors lo cqnstruct the projea(Sec.
Speciol Inspection 7044�Busireess anJ Profeaainns Coda:Tbe Contracior's
(Conc.)(Masonry�(Welding� � (.icense L.uu�dae.�not apply to ax owner o(pmpert3�whn
buJlJ.c or imjrrn��er thereon,and u•Gn covtnc�ts jor such
Lot Drainage prnjects udLh u rontrurtor(sJ Ircexsad�+�ir.euant to tl�e
ConxrucrnrS�I.iccruse l.um).
Parking � . .... ............ ....... ..... ;
/: rl I am exempt�nder Sec. ,B.&P.C.for ihls
�f��,".;�.C'�7t..�/ s�P / -/�', /'A4.''�r�- ..,,G._.- reoson . - . ..
� � Date Owner
�- ,.v s�;�;� '�� G� s'� fo`�6�'J�-. .. . .
V APProvals DaTe Inspeclor's ignat�re �
. , . INSPECTOR'S NOTES �
Location- ( � -.. . - .. ,...- .
(Setback&Y �1 � /� � �
Foundations ' . . -. . . . . . .. . -. , .. .. � �.
Slab ��.—r'•--� � .:. :.. . .... ......: . ..
Frame _�?.Y,-�' /Y IS,� . . . - . . ....,:.. .
Energy Insulation _� .-.__.. .,. •..-_.x.�....... . ...,.,..o.... . .
r
Lath/Drywall- �. , �, ,,.. . .. �.,. , . . , . _.. . . _ . . , .,.,-
Interior ""! ��Ze,rlfl.,�_�
Laih—Exterior � �� �
House Number ' - ' �� � �� - � � �
Correct&Posted - �- ��
Final— • . . . - -. . .. . . ... . . ..
Enter on Front � �