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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 � � �[? 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