HomeMy WebLinkAbout1507AWORKERS' COMPENSATION DECLARATION - II
I hereby affirm that 1 have n r nfir=`e of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or APPLICATION FOR BUILDING PERMIT
o certified copy thereof (Sec. 3800, Lab. C.) Fidelity & Casualty
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Relic No A()W8f1 5Z '' Arl-jsii Co t,f N Y `�` •�
Relic,
Certified copy is hereby furnished.
rot Certified copy is filed with the county building inspec-
L� tion department.
D.f.—l-22-82 Apolli,t 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) ar less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person r any manner
so as to become subject to the We r ' C°� m^pnensation Laws.
Date---1Applicant
NOTICETO APPLICANT: If, after making this Certificate of
Exempt Ior, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- --
with comply with such. provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby nffirm'hot I om licensed under provisions of Chapter 9 _
(commencing with Section 7000) of D- vision 3 of the Business and
Professions Code, and my licenses in full force and effect.
License Number 344019 Li, Class B-1
Contractor Cork Harbour Dote 1-22-82
tam exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No. Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is riot intended or offered for sale (Section
7044, Business and Professions Code).
1, 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
hereby affirm that there is a construction lending agency for
the performance of he work for which this permit is issued
(Sec. 3097, Ci, C.).
Tender's Name NONE
FOR APPLICANT TO FILL I N
BUILDING ,9 [
ADDRESS tdS J 1 %✓.f-. z- i.- �/! L
BUILDING
22852 Drive
ADDRESS Hilton Head
LOCALITY
CITv Diamond Bar ZIP 91765
NEAREST h'
CROSS STr
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT NOW ON LOT
MAP BOOK PAGE
PARCEL
36346 1
USE
MAP /,/,/-
TRACT BLOCK - LOl N
j
—, 3 //
i
If
OWNER Home Sav & Loan No. 385-19
-7 ci L'L-
SPECIAL
CONDITIONS
ADDRESS 3731 Wilshire Blvd.
DISTRICT GROUP I TYPE FIRE
CONST.. ZONE
I PROCESSED BY
11
16 /1;1j
CITY Los Angeles zip 90010
ACOND.
OR _
STATISTICAL CLASSIFICATION
ARCHITECT
C;INEER PRC TOUPS NC. A
CLASS NO. //— DWELL. UNITS—
NITSADDRESS
ADDRESS972 Town & Country/Orange
SEWER MAP
CONTRACTOR Cork Harbour No.
BK. PG,
VALIDATION
ADDRESS 22900 Golden Spr Llc. 344019
VALUATION
CITY Diamond Bar TIC, SS B-1
S 5200.00
1
t d.7 A
SO. FT,. NO. OF NO. OF CHECK
}j: o u . w 21
SIZE STORIES FAMILIES ONE
s
26.32
) -2632
DESCRIPTION OF WORK Carport NEW
Building ADD ❑
e A 2 6 e:2 U
ALTER ❑
FINADATE
-
0209-82
REPAIR ❑
USE OF❑.
DEMOL
FINAL
EXISTING BLDG,
Ru
AYYLILANI ItL.
pRINTI D.A. Mosiman NO. 594-184
N MOVING TEL a
_ Lender's Address PC Fee
I certify that I have read this application and state that the
obove information Is correct. I agree to comply with all County Inveslioc
ordinances and State laws relating to building construction,
ande%bto �entioned
t�j�rize representatives of this County to enter
up th . property for inspection purposes.
Signature of App ant or Agent Date
Permit Fee 5S_50
eFee 8.50
T- — 64.00
SEE REVERSE FOR EXPLANATORY LANGUAGE
As