HomeMy WebLinkAbout1516AWORKERS' CONi-ENSAT ON DECLARATION
hereby affirm cert that 1 have a certificate of consent to self APP.�-I-[ ATION _F®.K . BUILDING PERMIT
insure, or a certificate of Workers' Compenstion Insurance, or '- �'1 V!l Y
.certified copy thereof (Sec. 3800, Lab. C.) Fidelity & Casualty COUNTY OF LOS ANGELES - BUILDING AND SAFETY
PohcyNo.80w80 83�d�
9{i Co. of N.Yv
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date 2-1-82 Applicant D. A. Mosiman
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, i `hail not employ y per on in any manner
so as to become subject to the W rk r ompen- ic, Laws.
Data 2."1-8-2 APplcam t�E•'YY2
NOTICETO APPLICANT If, after making this Certificate of
Exemption, you should become subject to the Workers'
0
FOR APPLICANT TO FILL IN
aooe ss ,;" "'e' r' s
Vii;,£.° -t'
rJ''°`✓�
BUILDING
ADDRESS 22800
F. Hilton dead Dr.
LOCALITY
,;. /�.__., —/
'tor
CT1Dia.mond
Bar 7F 91765
CROOSSST.
� �%r� .r4�
VALIDATION
I
SIZE OF LOT
NO. OF BLDGS.
NOW ON LOT — 0—
ASSESSOR
MAP BOOK
- PAGE
PARCEL
TRACT 36346
BLOCK FT NO.
USE ZONE
e J _
MAP
NO.
(commencing with Section 70Wi of Division 3 of the Business and
Prefe sins Code, and my icense is In full force and effect.
CMDlamond Bar
OWN e Say,
Qf AfffericTEL385-1900
r/ f
Ico DITIONS
SCI. FT / , NO. OF NO. OF
�,�:'-}rt('BTORIESFAMILIES
Jes
CHECK
ONE
DISTRICT
GROUP TYPE
FIRE
PROCESSED BY
ADDRESS
5 'W__"
!�
CCINST.. Gl-
ZONE-
'
CITYin
ZIP
- STATISTICAL CLASSIFICATION
APT. CONDO.
ARCM IT OR
TEL —
ADD 0
4) '7i
® t 0 Q / 3 2 :a
licensed orcmicirt or a registered professional engineer
ENGINEER
FrOURF,NO
CLASS NO.
DWELL. UNITS
Compensation provisions of the Labor Code, you must forth-
ADDRLS597 2 Town & Country/Orange
LOCALITY
SEWER MAP
MOVING
with comply with such provisions or this permit shall be_
CONTRACTOR
NO NO.
deemed revoked.
CONTRACTOR Cork Harbour
NO BK.
59.
PG,
VALIDATION
LICENSED CONTRACTORS DECLARATION
LIC.
I hereby affirm that t am licensed underprovisions of Chapter 9
ADDRESS 2900 Golden. .ci. r
3V0- 34401
VALUATION
(commencing with Section 70Wi of Division 3 of the Business and
Prefe sins Code, and my icense is In full force and effect.
CMDlamond Bar
LIC.
CLASS B-1
s 483, 590.00
:2 15 1 6 A
344019 B—I
SCI. FT / , NO. OF NO. OF
�,�:'-}rt('BTORIESFAMILIES
Jes
CHECK
ONE
4. o a • e `2.'
License Number Lic. Class
SIZE�
NEW I
5 'W__"
1 1 0 0 63 2
Contractor Cork HarbourDate 2-1-82
DESCRIPTION OF WORK t
am exempt from the licensing requirements as I am a
ADD 0
® t 0 Q / 3 2 :a
licensed orcmicirt or a registered professional engineer
-
ALTER 0
FINAL
acting in my professional capacity (Section 7051,
REPAIR o
DATE
.8.2
02,09—
Business and Professions Code).
USE Of
�
FINAL
-
EXISTING BLDG.
ULMOL p
a.
Lic. or Reg. No. Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason {Section 7031.5, Business and
Professions Code):
F1I, as owner of the property, or my employees with
-wages as their sole compensation, will clothe work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
r7I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby offirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.I.
Lender's Name NONE
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and Stale laws relating to building construction,
an
eby ulhor ire representatives of this County to enter
rou on th��''cbo entioned property for inspection purposes,
a 11! 2-1-82
Tg`BWuTc of Applicant cr Agent Data
Is_... 22900 Golden Springs Dr.
—
BUILDI UII
LDING
ADDRESSR-
LOCALITY
MOVING
TFI
CONTRACTOR
NO NO.
f,y'®
Lee
Total Fee
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