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
. -____�-�.
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