Loading...
HomeMy WebLinkAbout1554A 1555A (9) WORKERS'COMPENSATION DECLARATION - - � �� i nereby afiirm that I have a certificote of[onsent to self �pp��,I�C�TIOIV FOR BUILDING PERMIT L4 �nsure,or a certificate of Workers'Compenstion Insurance,or a certified copy rhereaf(Sec.3800,�ab.C) COUNTY OF lOS ANGELES BUILDING AND SAPETY acyNo.763G-8118company Pac. Indemnity auaoiNc e���'C� Ce�tiHed copy is hereby fumished. FOR APPLICANT TO FILL IN A�DRE55 -"" C.� �Certified copy is filed wiih ihe county building inspeo- gua�WG ��73 Bj(��',.Z/�. 22,$]cj Hjj,'j'QN $$L� '�� j+�' . . �� lion department.� ADDRE55 LOCALITV S.McGinnis Diamond Bar zic 91765 cRossssr. Date App�icant CITY CERTIFICATE Of EXEMP710N FROM WORKERS' NO.OF BLDGS. ASSESSOR - COMPFNSAiION INSURANCE SIZE Of LOi NOW ON LOT O MAP BOOK PAGE PARCEL (This section need not be completed if ihe permi�is for one USE ZONE MAP "�`` ��/ hundred dollars($100)or less.) TRAQ BLOIX LOT NO. NO. r a �" i certif inat in the erformance of the wo�k fo�wh�ch this Ow�dea l�-.�f1tlklriS011 DBV. �c�188147i52 coNoii�ONS � Y P DISTRICT GROUP TYPE FIRE PROCESSED BY V permit is iss�ed,I shall not emplOy any person in any manner �DDRF55 1��1- COTIIIR2Y.'C2�pT. CONST. ZONE . � so as to become subject ro the Workers'Compensalion Laws. ? - Irwinda,le Z�P 91706 l L E� Y � Date App{icant — C'�Y — STATIST�CAL C�SSIhICAT10N APi, C DO. ARCHITECT OR iEL - 9�Y N O T I C E T O A P P L I C A N T: I f, a f 1 e r m a k i n g i h i s C e r f i f i c a t e of E N G I N E E R B&F'+ �'R . N O.Z 1 3 2 5�+5 1 3 � C L A 5 5 N O. � C W E L L.U N I T S_ y E x e m pf on, y o u sh ould bemme sub jeU to ihe Workers' comperisar(on provlsions ot,hP La6or codc,you musr Forrt,- �qppgEss 825 Colorado Blvd. LA 90041 s[wee nnav � wlih comply wlth such provisions or ihis perm'u shall be " 7EL deemFd re�oked. coNrencroe Ahmanson llev. No 714837127 BK. P�, vauonnoN LI:,ENSED CONTRAQORS DECLARATION � UG� . , I hereby affirm ihai I am Gcrnsed under provisions of Chapter 9 ADDftE55 23861 -El Toro NO. �+6Jrb88GB VALUATION (mmmencing with Sedion 7000)of Division 3 of ihe 8usiness ond LIC. ���� . Professions Code,and my license is in tuil force and effeci. Cliv El Toro C1a55 B"�- � 465688GBC B-1 sa-FT No.oF Nc.oF cHecK ="i �`',${`, License Number lic.Closs SIZE STORIES FAMILIES ONE � hAYkYYitlSPtit�'x�� NEW �] S #7-e s e�e 2 I Contracior nESCRINTiON OF WORK ��1A1�YkS�T1 �B'V �ote ADD ❑ � a °v()CI.� � I am e.empr from the licensing requirements as I am a C�RPOR.T.S licensed a�chilect or a rPgistered professional engineer . AUFR �� F�NAL � � � �� aciing in my professional mpacity (Section 7057, RfPAIR DATE �� ���;-� Business and Professions Code). u5E OF .. �: FINAL J'�� � f w�j u - EXISfING BLUG. UEMO�� By i/�;�(� Li[.ar Reg.No. Dafe APPLICNM 7EL. S i/ �._� . . � OWNER-BUILDER DECLARATION ipRINT) S.MCG1riR1S NO.]1!}$ ]_ i r,e�ebY off��m rhar i am exemPr r�om+he co�ira�ro�s u�e�5e Aooeess 22900 Golden Springs Diamond Ba Law for ihe following reqson(Section 703L5,Business and - , Professions Code): . ' PRESEM .�� J�,.�'i hi ❑ BUIIDING � m @ I, as owner of ine property, or my employees with ADDRE55 tp:e a �v� - wages os iheir sole compensation,will do ihe work and ip�AL'�TY � the sirocture is noi intended or otfered for sale(Section -- . �. � Q �j� ?�`, 7044,Business ond Professions Code). - MOVWG �E�� � � I,ps owner of�he property,om exclusively contracting '� CONTRAQOR J Nn� � � t � : /::ti wilh licensed contractors to consiruct the pro'�eci(Sec- : qpoRE55 tian 7044,Business aod Protessions Code�. — �i'� � �e.}?c� CONSTRUCTION LENDWG AGENCY REQUIRE� yqRD HVJY �OTALSBTBACK FROM EXIST. - - SET BACK FROP.L!NE WIDTH ''. I hereby offirm ihat there is a mnstrudion lending agency for feCNT � ihe performance of ihe work for which this permii is issued P.�. � . . � (Scc.3097,Civ.C.1. SIDE � � . P.L +, Lender's Nome ROII2 .�'e,�J @� !�� P.C.Fee$ �✓,�"P"� Permii Fee ^•�I• �'-� - lender's Address —_ ��. - r e ��'^� I cerfify thai I hove read this application and s�nie fhat the Iss�,ance _ _ � � � above information is corred-I ogree to comply with all County vesflgnrto�Fee / _ �" - . ordinonces and State laws relating to building mnstruction, ie'al Fe /'' . � ° and her aurhor ze representatives of this County to enrer � � � - po cve mrn oned prop�- for inspeciion purposes/� .. • , � U��-ynZy.� ,��-� /. [, SEE REVERSE F02 ERPIANATORY LANGUAGE . ' S�gnof�re of App mni or Agent �---1 L7` � � Js . -____�-�. � �" � 4 'v p CS� m 0. Q � e5 4 � fl O R) J �'e � � w � �n �O . x' O '3 t� n �w O � cY � (1 -n S � 4 =T a fl � � � 4 3 g ,:,�.A? �: �. 4�. � � � � m C� � 7 :0 3 � 3 a-o csz 3 Q Q -o ;i � p �Q � c �� c4 � n � 3 ^a a ''� c� 3 : � � a � -< � � cfl a=�� � c� a � p n � t'n fJ� '_ � P�' � q p n p 4 5 � � � � � ." �`0 �' ° � , ° � � a � `� ' � � m o i� O �6 O q�. � 49 �3 ✓O �' � ,_„ � I O � � ' � �i � — � � '� .� ta � ., � � � � � w � , � � � � � n � � ; � � � � �r � � � � � i� � � �. _ � � � � � �� °� � ti � " ; �`� � � 4 ° � � � 'o � BD � I� � �� � 9 �.�, es. � s � � y 1g ! � � � w � n -� � � ' � � � � Y � k � ° �^-�o a Q m�"A � t�a �' . � -� b.� o t"�S s�L m e'4 ��s a, �0 ,Y, • � 6 � 'y 6.C"`V "' �"�. A � O Y�.» u N�Q ❑M A� `V O S"C A m y S9 f9 Iv 4T Q �� �'s+ .p� L_i b p� � `� Oa�.ty' 9'vai c � �'�c.''d��'o C`^ �,'�`p A A Q�(� I � o Q ,� � ,'��� �f. „ ��''°,y m `y'D � p c " � "''A � s'�n n�N ro �a' � .,'Z. � n � o �� o�n � �y � � m 7�' � x.'s r.�''y �`"^ r '�u- nt n o � �'.a�^ �° �b� °� � " �' -. �. t�"N�'� c"o ,m C m e� .°� � c,-�°.,, � � � i ., � �'' �.MT"b'�e91.�v"e 7 � y� y�p"'�A f�.' '-�q�� O, O f-Dr p F Y � y Q'tS " -�i O a m5�. �°-�. �. �;R � m ta �m Q � c•�� � n�y � `D t:. �0'�' '�,m O � � s�A a ° -'e-" � � Q � Mt�,o °�..�x� .. � o � o� � � R���u,,�am�.�. n �3 � • �o � � °ro.. s a� o �"s � xiL d-a x .« p o � �� � � a c� 7� � �.,=i m � `� m "` �`-c x �,� � m"o `+,u, `",'cS n �e �A. £ x { e�n Q- � `�'' o ,��.�o ro `° o � �@ �.� °�„o Q v° *.��v;M A �� ° c" �1 y m 3 a m� y �"��`z::.H v ��� m�° o ;? � .c¢ �.� o�Cl��N� ,� x �Q C�' .a co � ti o o m �ti� o R. sa.� °< � � o � e�i'� ,�.�� m -„y I� o n �-P s o` m � tr o °j� � '.',.o. r m ro Q p `n � -� � ^e to O -t �o b Z" � A.r" O � ° N p '� A np..� no °. �'� �c ° »`^" m �. � �``'Q � �a� 9AR �`� 3 � y' , Z � :,� ai.`� � c%°K.�°a�`� c���3 a�A� � x C�h s°c? o � i � p,� <J � n K � �'� in'`�1 ��e�0 .;; �.O t�i O'�� �� c�i .� `�$'� A m O NN n o . m p R �-^ n r,o � � x 'A A s� ,p n� � g,R`� p R..v, - � c� O � ae° p � 'o+�e�o N '�+ � � �-�.,a�� o `°m� � a `�N ��``'Q ° �� V Q t 'm� � � � o ��° � � �� ° ry z"�5�-�-�`W o m �O��:,,ro 'c`�"o mw p � w� . 1 -�'u � ^} � °--� � a" " � � ° Cr•^ ,�� ca A �� ; `�'n� �-�•�- ° .S ' � � � � A n ? cCo �° � ;0 3V��,� �; �" �a ��`y � ,� � � 3^� �1 m �a pn T o �� � '4 1' p o � �O n Q ����� � "�^L� ` 0. . � I . ' S � a O a � __�-�.�--.... . .�--...,-- I m ' `-'_"_��^"`—�^`��� ` . .s....��—,..�...-^^..,..-,.....---""..�---"'�'.,_-------"'.,-.�--•,-,�" . .�...-..-.�.•'"`.'�.�,..,.,-T.'^"`.,.--^,