HomeMy WebLinkAbout1509AWORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 knee: onifieate of consem to se;.,
insure, or a certificate of Workers' Compence, stion Insuranor
a certified copy thereof (Sec. 3800, Lab. C.) Fidelity &
Policy No. 80W80 &$y96 Co. of N. Y.
Certified copy is hereby furnished.
f-1 Certified copy is filed with the county building inspec-
tion department.
Date 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 (9100) or less.)
I certify shot in the performance of the Work far which this
Permit is issued, I shall riot employ any person in any manner
so as to become subject to the Work Co pensati,n Laws.
1-22-82
Date Applicant
NOTICE TO APPLICANT: If, after makingthis 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 permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 70W) of Division 3 of the Business and
Professions Code, and my license is in full force and affep.
Li cense Number 344019 Li,. Class B-1
ta
Confrocr. Cork Harbour Date 1-22-82
❑ am exempt from the licensing requirements as I 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 shot 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
ages 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 the 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,
and preby authorize representatives of this County to enter
up tl!he a v mentioned property for inspection purposes.
st J 1-22-82
Signature of Applicant or Agent - Date
APPLICATION FOR BUILDING PERMIT
Casualty COUNTY OF LOS ANGELES BUILDING AND SAFETY ,jy 'I, -
FOR
FOR APPLICANT TO FILL IN
BUILDINGal
ADDRESS ✓CZ d' .R=- sf e..-4'. t^: ca' K,-+'
G 22852 Hilton Head Drive
(PRINT)
TOTAL SETBACK FROM EXIST.
LOCALITY
PROP. LINE WIDTH _
iamond Bar zip 91765
NEAREST
CROS ST
r
NO, OF BLDGS.
LOT NOW ON LOT —0—.
ASSE55OR
MAP BOOK
g.r
PAGE
PARCEL
!} 6 BLOCK LOl NO.
[ENGINEER
USE
MAP
NO, T J
SPECIAL
CONDITIONS
NO
- N0385-1900 .J'L7 la',.
3731 Wilshire Blvd.
DISTRICT GROUP TYPE FIRE
CONSt.,,� ZONE
PROCESSED BY
l ��
Tatar Fee 64.00
Los Angeles ZIP 90010
CT OR ` TEL, —
STATISTICAL CLASSIFICATION
APT. CONDO.
R PRC TOUPS NO. —
CLASS NO. i,?— DWELL. UNITS
ADDRESS 972 Town '& Country/0 nge
SEWER MAP
Tet.
CONTRACTOR Cork Harbour No 594-184
BK. PG,
VALIDATION
ADDRESS 22900 Golden Spr 34401
VALUATION
�' S C A
CITY Diamond Bar LIC. B-1
$ 5200.00
SO. FT. NO. OF NO. OF CHECK
4 o e • • 2]
SIZE STORIES FAMILIES ONE
1"'"EXISTING
$
! ® ®2632
DESCRIPTION of WORK Car ort NEW
Building ADD ❑
°`26325
ALTER ❑
FINADATE
X2,09--82
REPAIR ❑
USE OF
❑�
FINAL
BLDG. DEMOL
Rv
A PPLICANT
D. A. Moslma.n
TEL.
(PRINT)
NO.
TOTAL SETBACK FROM EXIST.
ADDRESS 22900 Golden Springs Drive
PROP. LINE WIDTH _
PRESENTBUILDIN
_
ADORE SS
LOCALITY
SIDE
r,/2
MOVING
TE L
26.32
C
CONTRACTOR
NO
Perm -a Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
�i
es
REQUIRED
TOTAL SETBACK FROM EXIST.
SET BACK YARD HWY
PROP. LINE WIDTH _
FRONT
P[
SIDE
JADD1115
PL
26.32
55.50..
P.C. Fee$
Perm -a Fee
8.50
uanc Fee
_e
Investigation Fee
Tatar Fee 64.00
SEE REVERSE FOR EXPLANATORY LANGUAGE
�i
es
El A '� % u C S }' Y c9
❑
% h H 6
&
•- A.
G m
y N cD
o
A Zi A o m e`er•. v
Q €- N O
mO O rw
O
.e v~'C• H 7 �.
�' @• `Ai O A A O Y O N w A N• .0
O S
�. A
N A N A
�• V Y O sa
A.w O A
o `� °�: `�� o �_
a
o a s1 0 0
% w O.0 J
_, w r
M Q �q
�0 ee. A O O 7 S `ori L W s� y O V
-Q"
A nw•1 � � R
O. A v � � C � (�D � "O � � .O. `y'V � O O C (D
NZS 2
may.. A O O
O .. 8
R. C a'7., " F3, W r• O Q (� u rwy O M C?J ��•- '-3 C%
�• _ m O .0
ySp $
y w O S` O A.
O H Q
N w O OR C w O O
y
A. v, til n
A. Y 'r • 2 L`•' w O C9 p RS r. A. O w p V, C)
,q.. �. p m A, �'
C A^. N
W
O S S m
y �# b w �'
J A. �"' o s• A A A.
�• �`r, c. 23�� p m O Z= y 0
A 'tl� 'o, a O A. �,.�, O
CD
e�..J
`�' r. � '� a `T• S, y`g^y ® W `w'. p �" � p � m 2 V �.
h��. e0+ �'<
b A �; y A � O t•rn N q tiO r"., Sw "�A �.S �O
o �^
O
O
y
Cn K �• n
ZIc'o w eOc O w
N