HomeMy WebLinkAbout1515A (8)WORKERS' COMPENSATION DT__KATION
I hereby affirm, that 1 have a certificate ;;f coram to self
insure, or a certificate of. Workers' Compenstion Ins4rc,ye, or
e certified copy thereof (Sec. 3800, Lab, C.) F`1Qe1'ty &
PolicyN§.OW80 838 y of N. Y.
Certified copy is hereby furnished.
Certified copy is filed with the county building iaspec-
tion department.
Date 2-1-82 Applicant D- 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 riot employ 'n'Y,p�Nllllyi.T
anner
so as to become subject to the W r er@'Laws.
Dare 2-1-8.2 Applicant 6` 1I
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licemed 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 3zId01 Q Lic. Class 1
Contractor Cork HarbourDate2-1-82
7 I aexempt from the licensing requirements as I o
limcensed 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
Law 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 properly, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code),
CONSTRUCTION LENDING AGENCY
I hereby affirm ,hot 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
Lender's Address _.
1 certify that I have read this application and state that the
above information is correct I agree to comply with all County
ordinonces,and State laws relating to building construction,
and hereby thorize representatives of this County to enter
�uPon t"dbo -mentioned property for inspection purposes.
f 2-1-82
Signature of Applicant or Agent Dote
l�
APPLICATION FOR BUILDING PERMIT
Casualty Co. COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
SEE REVERSE FOR EXPLANATORY LANGUAGE
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BUILDING A
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BUILDING 1
•
ADDRESS 22892 1
a
do Dead Dr.
LOCALITY
CITY Diamond Bar-
ZIP 91765
NEAREST
CROS55T.
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT
NOW ON LOT — O_
MAP BOOK
PAGE
PARCEL
TRACT 36346 BLOCK
IENGINEERPRCCT
/y
LOT NOr/
USE ZONE
3 J
MAP
No.
/
OWNER
TEL.
ir' ��
SPECIAL
CONDITIONS
ADDRES53731 Wilshire Blvd.
DISTRICT
GROUP TYPE
CONST...®
FIRE
LONE
PROCESSED BY
OTY Los Angeles
ZIP90019
AROR
TO L. —
STATISTICAL CLASSIFICATION
V
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APT_ CONDO.
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T UP
NO
CLASS NO.
DWELL. UNITSt/
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Ountr Oran E
SEWER MAF
ToCork Harbour
TEL. —
Nn
BK.
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VALIDATION
uc.
29 Golden
c 3
VALUATION
1 5 1, 5 A
LIC
Cws _
8511
300.0
NO. OF
FBLDG.
NO. OF CHECK
#®I® m -B 21
['-a STORIESNEw
1.058,40
ION OF WORK
ADD
❑
4 i.o58.4oALTER
❑DAEL
G?,CJ9`82
REPAIR
❑-
BLDG.
DEMOL
FINAL
Rv
SEE REVERSE FOR EXPLANATORY LANGUAGE
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