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HomeMy WebLinkAbout1502AWORKERS' COMPENSATION DECLARATION I herebv aff,rm that I hn cote of co �. .� ��i insure, or a certificate of Workers'�Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) Fidelity & Policy No,8HWRn R3:8r@a Cry of T.Y. Certified copy is hereby furnished. ©Certified copy is filed with the county building inspec- tion department. Date 2-1-82-Appllcci A. Mosiman CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work far which this permit is issued, I shall not employ any person in any manner so as to become subject to the W rkers CXn,, Laws. Date —1'—g2 Appl icon NOTICE TO APPLICANT: If, after making this Cerlificate of Exemption, you should become subject to the - Workers' Compensation provisions of the Labor Code, you most forth- with comply with such provisions or this permit shall be deemed revoked. I ICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commenting with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number 344019 Lic.Class TA -1 ContractorCork Harbour Date 2-1-82 I am exempt from The licensing requirements as I 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 Low for the following reason (Section 7031.5, Business and Professions Code): _ 1, as owner of the property, or my employees with ages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). rICA1 IVI�I F BUILDINGPERMIT Casualty COUNTY OF LOS ANGELES BUILDING AND SAFETY FO APPLICANT T F LL IN BUILDING ADDRESS „' v,aZ f ' '-/%? . /Ld- y ✓i BUILDING ADDRESS `+ ® ,y LOCALITY TEL. Diamond Bar CITY zip 91765 NEAREST CROSS NEARESr. - NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACT 3 6 3 4 6 BLOCK LOT NO USE 10MAP g No. _ TEL. SPECIAL OWNS O. — e) -- CONDITIONS ADDRESS3731 Wilshire Blvd. DISTRICT GROUP TYPE FIRE CONST. �. ZONE„ PROCESSED BY ( 0 `— �j v'�/�F-l�r-e>x..+' CITY __ ZIP, _ OR STATISTICAL CLASSIFICATION APT. CONDO. ENGINARCHEER PRC TOUPS NO. — ENGI (JEER CLASS NO. /,�_l DWELL. UNITS_ ADDRESS972 Town & Country/Orange SEWER MAP TEL. 7t 4 — CONTRACTORCork Harbour NO. RK. PG, VALIDATION - Golden S 344019 ADDREss22900 rgs;c. VALUATION L91 50,2A CITYDiamond Bar CLASS B-1 $ 5200.00 4 .. , 0 211 5(]. FT. NO. OF NO. OF CHECK - 51ZE STORIES FAMILIES ONE DESCRIPTION OF WORK Garpert NEW HJ $ • . . 26,3(2 ADD � Building ALTER FINAL 0209-8-2 REPAIR DATE USE OF EXISTING BLDG. DEMOt FINAL ev APPLICANT TEL. — PRESENT BUIIDING ADDRESS t✓ LOCALITY MOVING TEL. REQUIRED SET BACK P.L. Lender's Name Nnmp. Lender's Address P.C. Fee $ 1 certify that I hove read this application and state that the above information is correct. I agree to comply with all County Invesrigoti ordinances and State laws relating to building conmr-Hon, and ereb aufhorire representatives of this County to enter on n th he.. Ove -mentioned property far inspection purposes - 2 -1-82 S n tune of Applicant o, Ag— Date YARD HWY TOTAL SETBACK FROM PROP. LINE Permit Fee 55F ante Fee Fce ' Total Fee c n n SEE REVERSE FOR EXPLANATORY LANGUAGE Ts