HomeMy WebLinkAbout1508A (8)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -
insure, ora certificate of Workers' Compenstion Instt��ran$$et or
a certified copy thereof (Sec. 3800, Lab. C.) F'1C1e11 ty &
Policy No. 8OW80 8_�8P do�y6 Co. of N.Y.
Certified copy is hereby furnished.
Certified ropy is filed with the county building inspec-
tion department.
Dote 1-22-82 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, 1 shall not employ any person in any manner
so as to become subject to the Wor ls' oibpansation Laws.
Date 1 —77—�� Applicant _' 9 8'iKT-'T'S
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permil shall be
deemed revoked. -
LICENSED CONTRACTORS DECLARATION
I heroby affirm that I am licensed under provisions of Chapter 9
(comrnencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect_
License Number 344019 Lic. Class a—1
Contractor Cork HarbourDate_ 1-22-82
❑ am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting in ❑y 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
Low for the following reason (Section 7031.5, Business and
Professions Code):
1, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
I, 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 affirm that there is a construction lending agency for
the performance of iho. work for which this permit is issued
(Sec 3097, Civ. C. ).
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 State laws relating to building construction,
andytrerehv
u prize representatives of this County to enter
Ve- entianed property for inspection purposes.
tin 1-22-82
Siynolure of Applicant or Agent Dme
I
APPLICATION FOR BUILDING PERMIT
Casualty COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
A�oeess <�� r� / �-
? <
BUILDING 22852 Hilton Head Drive
ADDRESS
LOCALITY .;.� e*�-- ! -� 'lw�'.°'�•V
iamond Bar 91765
CITY7'F'��" ZIP
NEARFST -
S CROSST.-'~..-Lv-CZE.`
NO. OfBLDGS.
ASSESSOR
SIZE OF LOT NOw ON LOT —0—
MAP BOOK PAGE
PARCEL
1
LSE ZONE
MAP
TRACT 6346 BLOCK LOT NO.
TEL. 213 —
OWNER NO. _
M1
30 Lti.
SPECIAL
.CONDITIONS '
ADDRESS 3731 Wilshire Blvd.
DISTRICT GROU
RP CONSi;�-' ZONE
PROCESSED BY
1Z) 517
CITY Los Angeles zip 90010
ARCHITECT OR TEL. t 14 —
SIAHSTICAL CLASSIFICATION
APT. CONDO.
ENGINEER PRC hl NO
CLASS NO. f.Z— DWELL. UNITS_
ADDRESS 972 Town & Country/ Orange
SEWER MAP
TEI-
CONTRACTOR, Cork Harbour NG.
BKPG,
.
VALIDATION
LIC
ADDRESSC�nldem 34401
VALUATION
F
z 1 -0 8 A
CITY Diamond Bar CLASS B-1
$ 5200.00
50. FT. NO. OF NO, OF CHECK
f% w . o e 21
SIZE STORIES FAMILIES ONE
-
$
1,--2632
DESCRIPTION OF WORK Carport NEW
F1
®e e 26,32
BuildingADO
ALTER []
Q 2 0 9- 8 2
REPAIR
DATtL
USE OF -
LEMOL ❑
FINAL
EXISTING BLDG.
APP! IrANT TF1 y
B Y
SEE REVERSE FOR EXPLANATORY LANGUAGE
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