HomeMy WebLinkAbout1504A (8)WORKERS' COMPENSATION DECLARATION I
insure, or arcerrttifcatelof Workers' CompensafionInsurance, or APPLICATION FOR BUILDING PERMIT v
o certified copy thereof (Sec. 31800, Lab. C.)Fidelity & Casualty COUNTY OF LOS ANGELES BUILDING AND SAFETY' / /e -e
PolicyNo.80w80 83figlIcig O —Y
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Dote 2-1-82 ApplicanD. 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 for which this
permit is Issued, I shall not employ y person in any manner
so as to become subject to the. W r lI; ompansation Laws.
Date z-1-82 _ Applicant L'
NOTICE TO APPLICANT: If, after making this C.rtificate of
Exemption,you should become subject to the Workers'
m
Copensation provisions of the Labor Code, you most forth-
with comply with such provisions or this permit shall be
deemed revoked,
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of. Division 3 of the Business and
Professions Code, and my license Is in full force and effect,
License Number 34401 O. Lic. Class R-1
Contractor Cork HarboU1z Date 2-1-82
I am exempt from the licensing requirements as I am a
licensedarchitect 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):
�. I, as owner of the property, or my employees with
wages 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.).
Lender's Name NONE
FOR APPLICANT TO FILL IN
aON
BUILDING
NG Carport #100
SS
F. Hilton He—a-4—
ft2.`d&>-,.r_y*.*-^'�.'
LOCALITY22892
.
NEAREST t
-
Diamond Bar ZIP 917
CRosssT.
NO. OF BLDGS.
ASSESSOR a
F LOT NOW ON LOT
MAP BOOK PAGE
PARCEL
BLOCK LO7 NO.
USE ZONE
''
MAP /
NO. ! i' fl ` -� y,!_ f
TEL
R
[CONTRACTOR
—
_
`-`' ==`L.-
SPECIAL
CONDITIONS
DISTRICT GROUP .TYPE FIRE
PROCESSED BY
SS
CONST. ZONE
ZIPTECT OR TEL.
_STATISTICAL
CLASSIFICATION
APT. CONDO.
EER NO
CLASS NO. -� DWELL UNITSSS
SEWER MAP
TOR Cork Harbour Np
BK. PC,
VALIDATION
22900 Golden S.r LIc
344019
VALUATION
amond Bar Lass
B-1
5200.00
_'1504A
s
NO. OF NO. OF
CHECK
#. ® o a `2 i1
STORIES FAMILIES
ONE
OF WORK Carport
rI.IIII'tDIG
NEW
�
$
I, -Q ® 2632
ding
ADD
❑
... . 2632=
U
ALTER
❑
FIN L
�. p q r g,2
REPAIR
❑
BLDG.
CEMOL
E]
FINAL
RV
40'5
PRINT) A_ Mosima.n Nor.594-184
ADD,,+,=22900 Golden StDrinas Drive
BUILDING
ADDRESS
MOVING
Lender's Address P.C. Fee
I certify that I have read this application and state that the
aabove information is correct. I agree to comply with all County Inves!igc
ordinances and State laws relating to building construction,
and hereb authorize representatives of this County to enter
aup n,t —mentioned property for inspection purposes.
5,3 ture tf Applicant or Agent Date
Aq
N 0-
O.
2b. 32 PermTFee 55.50
eFee 8.50
F-
T.,,,] Fee 64.00
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