HomeMy WebLinkAbout1512AWORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 h --e a cert `:imra of cansen; to self
insure, or a certificate of Workers' CompensLon Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)Fidelity &
Policy No.80W80 8 Y.
Certified copy is hereby furnished,
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 sectionneed 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
P
ermit is issued, I shall not employ any person in any manner
so as to becorne subject to The W r ' Co}mpensation Laws.
�
Date 1-22-82 Appiimnf
NOTICE TO APPLICANT: If, atter making this Certificate of
Exemption, you should 'become subject to rhe. Workers'
Compensation provisions of the Labor Cade, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am hi onsed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 344019 Tic. Class — }
-
Contractor Cork HarbourDate1-22_82
❑ I am 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 not 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 -
Tian 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construciion 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 oll County
ordinances and State laws relating to building construction,
and herby authorize representatives of this County to enter
upor the h -n =ntioned property for inspection purposes.
M'P. , 4. 1-22-82
Signature of Applicant nr Agent Dare
APPLICATION FOR BUILDING PERMIT
Casualty COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN 1
ADDREss�-
CONTRACTOR
BUILDING 22852Hilton Head Drive
ADDRESS
{�. 7
LOCALITY
CITY Diamond Bar zip 91765
NEAREST
CROSSST.l_r.__--
NO. OF BLDGS,
O
ASSESSOR
FRONT
_
SIZE OF LOT NOW ON LOT —
MAP BOOK PAGE
PARCEL
_
TRACT 36346 1 BLOCK LOFT 21 3
USE ZONE�'�
MAP
TEL.
OWNER Home Sav & No. 385-190
4f-` L,L—
SPECIAL
CONDITIONS
8.50
_Loan
DISTRICT GROUP. TYPE FIRE
PROCESSED BV
ADDRESS 3731 Wilshire Blvd.
corvsT. zoNE
Total Fee
e
,dl
CITYLos Angeles LIP 90
ARCHITECT OR TEL. —
FNGIP!EER PRC TOUPS NO —
STATISTICAL CLASSIFICATION
CLASS NO.—[,,?— DWELL. UNITS_
APT. CONDO.
ADDRESS 972- Town & County O an e
SEWER MAP
CONTRACTOR Cork Harbour I,, —ELK
PG,
VALIDATION
ADDRE5522900 Golden s r q s�o. 344019
VALUATION
.`_' 15 1.2 A -
Diamond Bar CB -1
S 5200.00
CITY LASS#a
.21
SQ. ET. NO. OF NO. OF CHECK
-
SIZE STORIES FAMILIES ONE
1®-26.32
DESCRIPTION OF WORK Carport NEW El
5
®re w2
13
BuildingADD
ALTER ❑
FINAL
0 2 0 9- H 2
REPAIR ❑
DATE
USE OF
EXISTING BLDG. DEMOL ❑.
FINAL
Ev
APPLICANT TEI.
(PRINT) D. A. Mosiman No594-1841
ADDRESS 22900 Golden Springs Drive
PRESENT
BUILDING ✓9
ADDRESS
LOCALITY /` I
J %3
MOVING
TEL.
CONTRACTOR
NO.
ADDRESS
REQUIRED
TOTAL SETBACK FROM EXIST
SET BACK YARD HWY
PROP. LINE WIDTH
FRONT
P
SIDE
P!
P.C. Fees 26.32
Permit Fee 55.50
8.50
an
Issu e Fee
Invesrlgetlon Fee
64.00
Total Fee
SEE REVERSE FOR EXPLANATORY -LANGUAGE - --
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