HomeMy WebLinkAbout1016A 1628A (5) ._ ._ ._ . `
' .WORKERS'COMPENSATION OECLARATION • . . . . . . � . .. � + � ` v �. ��� ,
I�hereby pflirm Ihat I have a cerlifimte oi�o�=e�,,o=e�f: .. � . �APPLICATION FOR BUILDING PERMIT � �� �-�_-��
insure,a�o certfficate of Workers'Compenstion Insorance,or , '
a c rrf' d iher f(ec.3800,Lq C.) ' "� • -"'�OUNTY OF'LOS"ANGELES� BUILDING AND SAFETY
Po��8�� ���34 ��.l�am PaClfic Indetrmity Group `` '
P Y
O Cerrified copy�s hereby furnished. � . FOR APPLICANT TO FILL�IN ADDRE55 v'�•�9� t..✓ �'
� � Certified copy is filed wilh ihe counly buildioq inspec- BUILDING'"� ' �' � ^�� i••^; �.�•',+ .
tiqn departmeni. , ' � � qooeeSS 22900 Goldeil`� ri` ��s Dr.� iocnuTr -�.�.,w i �
A. D. Harper �Diamond Bar 91765 NEaResT
��Dare Applicant �� � �� CITY. � LP Ca0555T.�
� C RTIfiCATE OF EXEMPTION FROM WORKERS' � ` • --�� - NO.OP BLDGS. ASSESSOR . �
� � COMPENSATION INSURANCE � --�" �- � SIZPOF�LOt` . .NOW ON l0T —�— MAP BOOK PAGE PARCEL
�(This section need nof be completed if}he permil fs 1or one TRACT 363A6 � n USE ZONE MnP
hondred dollars(SI00)ar less.� �.. � � � B��K • � LOT �/ �'J7, NO. — � ,r �
�y-�� .SdVl s of Americ.'��' SPECiAI 4
OWNER"""' � o. 3851900 �7"1� CONDITIONS
I cerrify t6ot in Ihe perFormance of the work for which this � � � �
oISTRICT GROUP TYPE FIRE PRpCESSED BV
,permil is issued,I shall nof employ pny person in any manner V
nooaes 3731 Wilshire Bl�. CONST. 20NE
�so as io become su6ject to Ihe Workers'Compensolion lows. ' � /O M
� aTvLos An eles z�v 90010 �
Dafe � ' '� ApplifOn� - ' STATISTICAL C�SSIiICATION� APT. CONDp,
� NOTICE TO�APPLICANT: If, a(Ier making this Certificofe of - � ARCHITECTOR �G` �jllp5 � - N� � p' w
� Exemplion, you�Should become subjecf fo the Workers' ; . ENGINEER CLA55 NO. � DWELt.UNITS � 0.
Cam ensalion rovisions af the Labor Code, ou must forlh= �
P P Y ADDRE55 972 TOWIl &�COUI1tL'y R C SEWER MAP Z
with comply with wch provisions or this permif sholl be �
deemed revoked.�, � . .. . . � CONTRACTO�QR2 SdV1 S NO aK. PG, . � VAUDATION� ,
�� �,� LICENSEDCONTRACTORS'DECLARATION � � � . S2� a�lOve "�� 147919 � '
I hereby afFirm ihat I am licensed under provisions of Chapter 9 ..._.. ADDRESS.. .--. NO. VALUATION � �
(commencing with Section 7000)of Division 3 of the Business ond . LIC. - . .. . .
Professions Code,and my license�s in full force and effecl.- Ciiv C�ASS . B"1 3"IQ�463 - �
147919 B-1 SQEFT TORIOES i MI101ES CD EK
License Number Lic.Class E � e�Q�,b�A.
tyrm Savi S OP nm ' DESCRIPTION OF WORK Ret31.I71IKJ Wd�.1S NEW � # •�•2 3
Conrractot^^•"' � `9G1e ❑ � ' • •
.._. . . . .. . . . . ADD - .
� I am eaempt from the litensing requ"vements as I am a #35— $0'XL��� 108�X$� �
licensed arthitect or a iegistered professivnal engineer' , , _.. . , , , , , ALTER � FINAL���/ ry � • '7 Q�3
. acting in my professional mpocity (Secllon 7051,- � 36-�68'x6� � QEPA�R � DATE lv J ��� �7a13�
Business and ProFessions Code). USE oF , � � � � �
� � EXISTING BLDG. � � DEMOL ❑ FINAL
Lic.or Reg.No. . .. ....' . . . .Dote ... . nFvuCnNi TE� y 0,1,1 3—8 4
I '- � OWNER-BUILDER DECIARATION � -(PRiNt�A. D. r- No861-2311 , �
I hereby o1(irm thot I om exempt from�he Contractor's license � aoDaE55 GOLC�QY1 S L1I1 S �I" DB � � � � � �
. Law for the following reoson.(Settion 7031.5, Business and � , � ' �
Prafessians Code): � � aeESEw � `
. ❑ . ' .. ' -... .. BUILDING . . . . ` ` , .
I, os owner of Ihe properfy, or my employees wilh ADDRESS � �-.�� �.j
wages as lheir sole mmpensntion,will do�he wp!k a�d `-.+.,�. -� � �1'.!1:r�.; � ' �
-� � —the strocrore is not intended or offered for sale(Section ��/+IiTV �� � �'.;`j'•,;`�,,„� . �,:F•� � .
�7044,Business and Prolessions Code). MOVING TEL � � ,'���::.� � � � �� 6 2 8 A '
� �� I,�ai owner af the properly,om exclusively commcting CONTRACTOR C7 � - NO. '
. with licensed contractors lo construc��he projed(Sec- qoDRe55 - � ' �I• • • • • �
- tion 7044,Business and Professions Code�,��� � � � - ,
REOUIRED TOiAL SETBAIX FROM E%ISi. �
� - CONSTRUCT�ON IEN�ING AGENCY SET BAIX �YARD HWY pgOP.LWE WIDiH � I • •�J 3.O O �
�� I hereby a(firm�hot there is o construction lending oqency for paoNi � '� �� '� , • " �
rhe performance of the work for which�his permii is issued a.i. ' • •f��Q Q�
' . ($et.3097.Civ.C.L . . . , . . . _ SIDE . . - . .- . � •
None '`. �217-84
lendei s Nome y / .
.. � . .. .. . P.0 Fee S �Q• �✓ 7ermil Fee � J O � . . . , .. . .. . .
Lender's Address �)
I certify ihai I have read this opplica�ion and state tho�the � iesu ce Fee �%✓" .� �
o6ove informolion Is correct.I ag�ee lo tomply wilh all County . Invesiigo�'�on Fee. �� . - . . . _ � � . � ,
� ord�nonces and Slate lows relo�inq to building construction, � To�ol fee ,�J� , r� .
ond hereby authorize representotives of this Coonty lo enier , . � .
.� upd a6o�e-mentio p�operty for inspeUion pwposes. , . - . � � �
n
SEE REYERSE FOR E%PLANATORY IANGUAGE
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