HomeMy WebLinkAbout1513A (8) � WORKERS'COMPENSATION DECLARATION ��
� insurehorafcertificatelof Workers�Compenstioo In uran�e�or r\������' ��/� �C7� ��1�1��I,iV�G �ERMIT ` �
a certified copy thereaf(Sec 3800,Lab.C.) F1ClelltY & C35Udlty CdUNTY OF LOS ANGELES 6UILDING AND 5AfETY �f
Pou�yNo.80W80 838�f�,6 Co. of N.Y. -
Certified m s hereb furnished. BUILDING„, i
❑ Pv' Y FOR APPLICANT TO FILL IN nooREss .:��.a�-r' c.t'-��-�-:-��z`i•_,�rl�.c��
� Certifled mpy is filed with the county buiiding Inspec- BUItDING zz8rj2 [j11tOri Head IJY'1V2Q
Ifion deporimenf. ADDRE55 t� LOCALI7Y �'.c'+�-�a�=�-lB,L.�� ��.t✓
I 1=22-82 D. A. Mosiman Diamond Bar 91765 NE'°RFs' �{
Date Applicant CITY ZIP CRO55 ST. •��`-/-E���.-w% _-y„� �,.,,,.e.r �
CERTIFICATE OF EXEMPTIpN FROM WORKERS' No.OP BLDGS. ASSE550R ��
ICOMPENSATION INSURANCE SIZE OF LOT NOW ON LOT —O— MAP BOOK PACE PAHCEL'�
i (This se<tion need noi be mmpleted if Ihe permit is for one t15E 70NE N�AP �,+ ,�t�-f
�' hundred dollars{$100)or less.) .. TRnCT BLOIX LOi NO. 3 NO. dj✓°7"'
� � TeL — �}'� SPECIAL �
I certify thot in the performance of the work for which this �'�`�NER ome ,Sav & Loan ND. _ � [� tL- CONDITIONS �
permii is issued,I shall noi employ qny person in any monner - DISTRICT GROU6 TYPE FIRE PROCESSED BY �
ao�aEss 3731 [�Silshire $lvd. coNsr. zoNe
so as to become subjecl b the Wo,Jr,�7g�r'-C,ompensation Lows. . �T'` : !iC
. . !i ��1� f� r7 ..--�
Dafe 1—zz-82Applican- ��ti^'�"!`"='�� CI7Y LOS AYl eles ZIP 9��1� STAT�TICALCLASSIFICATION ANT. CONDO. �
N0710E TO APNLICANT� If, afrer m'"��ak g�rhis Cerfificnte of ARCHITEQOR TE6. ZQ— ,�� �
exempricn, yoo should becomc sub�act ro the workers' ENGi"F`R PRC TOUPS tvo. uass No. , oweu.uN�Ts, �
Off
Compensation provisions af ihe Lobor Code,you must forth- aoouEss�g']Z 2'OWYl & Countr �Y' 17 � SEWER l,MP �
with rnmply wifh such provisions or this�permif shall be
deemed revoked. CONTRACTOR Np_ BK. - PG, VALIDATION
LICENSED CONTRAC70R5 DECLARATION ��`
i r,���eY a+t�,m�h��i�m u�e�sed��de,p,ov;s;a„s�r chaPre�e aoo�zessz 2 00 Gold n r 344 VALUATION �� 5�,3 p
(commencing with Section 7000)of Division 3 of the Business and ��� �
P,oreSs���s code,a�d mY u�e�se�s r f�,u fo,«a�d et+P��. oTv Di mond Bar c�nss _1 s 5200.00 #�e a � •2 1
SCE.FT. NO.OF NO.OF CHECK
u«�s�N��„hP, 3 a a n�A uc.c��ss $—� sizt sroRies Fanniues oNe I • •2 G 3 2
y
ConrroaorCc�rk Ha rhni�r oare�—��—R� oEscRiPnoN oF wokK CaZ' oI't NEw �] �e����U
� I nm eaempt from the licensing requiremenis as I om o Bui lding v_` ^oD ❑ '. -
licensed orchi�ecf or a-registered professional zngineer ALTER � FiNAI � O Z,O G`g 2
acting in ny professional copocity (Section 7051, � � DATE �
REPAiR
Business and Professions Code). � USE OF � ❑. P1NA4
�� EXISTI�G BLDG. �EMOL B �
Y
Lic.orReg.No. Dafe � AGPIICANT D,A. Mosiman �o. 594-184 ''.
OWNER-BUILDER DECLARATION � . �PRwi�
I hareby affirm thar I am exempf from the Coniractor's License - . .
Lqw for the following reason (SeUian 7031.5,�Business ond AD�RESS 22900 Golden $X3Y'111 S Drive`..
Professions Code): . FRESENT � �
❑ . BUILDING . �^
I, os owner of the property, or my employees with ADDRE55 /�J
wages as!heir sole tompensaiion,wil l do ihe work and � j rL'.�� �
ihe strucWre is not iniended or offered for sale(Setiion �OCALITY � � � ,
7044,B�siness and Professions Code). MOVING TEL.
� I,ps owner of ihe property,am exclusively coNraciing �ONTRACTOR NO. lp� .
with licensed conirac�ors to construct the projetl(Seo qD�RESS �/�/
tion 7044,B�siness dnd Professions Code). ,
RFQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUQION LENDING AGENCY SET.BACK YAko HWY aROP.uNE WIDTH
I he�eby affirm ihaf there is a mnstruction lending agency`or FRpNT
the performance of the work ior whicn thls permi;is issoed p_�. �
(Sec.3097,Civ.C.J. SIDE � �
NONE P�
�ender's Nnme �
lender's Address ec_Fee$ Perm�t Poe �� .
I certlfy thar I have read this applimtion and state that ihe issu ce Fae $•50� �
- above informa�ion is correct.I agree b comply wlih all Coun�y Imearrgaibn Fee � '
ordinances and Staie laws-relating�o building mnstruction, ior�l Fee 64'•�� ��`
and ehy_authorize representatives of ihis County to enter �i-�.
0
up th v�-mentioned property for inspe<tion purposes.�� � .
� ,f�} L, . � ].-22—$z SEEREVERSEFOREXPLANATOR7LANGUAGE � �
' SlgnoNre o{Applicanr or Aganf Dare ' - OOs
..,�'n x mrt,-n V,�'„ �O � _..,._.9_..._o.._..._.��.�._.�_.__�`�_��r_.�._..� _— � � t---5-„-�"`wj`""�
= R � � � p
� oo ° ° � fl o ° rn � � a � __;� ca o � n � Q � !
cD Gl � c v s � Cr � c'? _ V 3':+' n ro� fl- q ' ro �
p �� �P '��' 0' Q Q O �, � f:. .^ Q ;m � � ta � S C�
-'nI R'� m o�� y a �„ I '� fl �a n� Q ° � �' D
� � zs
-o� -. � p c y o � Q-rs ° -v � n = �
� � a' O 9 O 4"a O'� `G p Ce' C O �
Q i � o� � w � � m � 3 � e ca
3 j "-ll. 7 u fS
O
� 7 .
�
a r
� A
� ° � `�^
� �
1 '° e � �
� � � �
_ � � �
` ;
z � v = m
» a m a �
�
0
�
o � �
� �
w ��+
a � � �
o �
m � �
� �.� �
z
�
a �
�,
�
�
0
. �
w
, z
0
�i
�
�
I
�
� �[? Q��"V�` O„�e.' S''g O r�S f t5' kS A (��,.i �K„��. � Q7 r'
Q Q ❑ � O .�,. n�A�� � +o �ga � C o �•� � � tp � A� 'a�5 �A.3 n �A �� `°•', 3 N
Cp p. �m'�S 'A 'C� � � m m � �� ��� v�, .�*..,`� eo �..�t c � R,+'t? k� N
� A �, o � IXl� — ^�t �`o.,m a�� � y n fl - �`�',A.o p y`m b �'``°' � c0 6'
Q o �c ^,N s� O'o,� `° � � `' A � `" a °,h k p*•�A � ? a Q'� �
. � y � . s• � ep b� � �3°y cT�y � � � s � Y� ro A ��.� � 'y � fl ,C`
x P A o °w � � y�.ro�u'�i o m� �� � � ���.m b� � o� „�,� o� ri9
�
3 �' c `�,' A o_ :o a � �.:.; s a"�e�ti,° ° m � � � U'��r'�.°`� � "�� '''tl
� y o `y° � a.c, °, :°���„ x �a"O � `z h �_ fD O � 'e� �' � �`�' � � � y s Q �
,� � o �' co � n � N ,'�,� o � � n � n a' � -• �
c�o: � � � s b? s M� �c `" �a � o o'm o � �y �-c� o � —r�
� Q Q a ,i0,w o Q m v° �''n' a � Q� m Q q`z'� "��A�b' y o° C7
� . . � � ` � p�'N`-' 'o � tS'� �.� O�.,e`3 m D.� '� ..' C o A � 'S .�. y � � Ctj
� <n .� � � ° o `° c � s 'z � o o a 3 'r,ti o. �,`cr � o'� o a �
� �° �� o ° N c��o �'��ro' m� o� �° Q� w.v�M m s-� o » � » ro �, X •L
� � c> � ° ti�s � 0. sa,m y°o � � " ° �,� �s,c °'�� ca � �
� � � �o �� Q ° cb� ° o � o3�c� � " � � �-n�,�`' m� � r
i � � o� c�a�� 3 cr�.'° o ` �'� ��o �. Q m ��a � � � A �' � � ° o�
� � �'n :� n x �•co�.���° ° p—� �A m� � � 6, A �o ° �
3 y � a� °v� 0.�; K' �'cy � � �"
. E . �'� o S ^_ �Y^� a m � m � ° m �"h R � o�� m o '� �-"'�
- � .0 `'M� s N � 6 F1.ca � "n. A Q' j''•T':P.n 'a2 n CG �
. � � � Q � �� ` � �, �o � �� o � �° � � � �A'��o P.Q.� � m��
� � �� °� °.� �, w� `' �, s`s•�•m o m �`" pA.o � r'.`a' � �^� `-' °
. , - C) `q.,q (0 `5 [1 10' �n N. � O n �O W �'h • � V-
� � A � � � L+ u Sa �y �h" �y O a �,O y gc*.� tJ� ��' O❑
. . � � p , c � 7 � m :3 ca m � m �I �O n �n� : f�� � $, w n
" C � Cn O `�+. � Q � d. Q� "�O t0 'v,' O
s cgM-n ��a � Q o S•� �.�o �v�,.Q � - ti w �S�� n ti�� �o �."ra `,?., tn
� �c � �c ro m� , �a �, w rz�- P.;� m �, y - �
6