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HomeMy WebLinkAbout0800A 0801A _ , .. .,. _, ___... __._.. _ . ._.... _... -- ------- .. WORKERS'COMPENSATION DEGLAaATION : .. . ._ ;: ,.:. �- ._..___._" "."."'-`--I'.._'_. ."';..n.'---_-"�_ -".. ..__..__....__ . . . . _ 3 1 here6y'affrm�hat I have a.cert�fimte of�consent to self APPLICATIDN� FOR�:.B�UILD�ING� PERMIT����-� �� �insme;or a cert ficale o(Workers'Compensa�ion Insurance, � br a Fertified cop'y thereof(Sec.3800,lob.C.) -.... . . .. ... . . . . .._. - .. ... . . . . .__ _. .__.._.. � �-• � � COUNTY OF LOS ANGELES � � BUILDING_AND SAFETY •. •1 v ���tEIX7�A3 a v Hertford..'G'roun �- -. - . Polic No. m on ._. �CertiFled copy ii hereby fumished.�� �• � � �• BUttDING � � � FOR APPLICANT TO FILL IN ; nooeess f D � Cerfified�copyisfiled'wit6ih�ecovnty6uildinginspec- -"-"" BUILDING i '�tion depariment.�� '-�' � � ��•� � ADDaE55 1079 South Lon Vl 2W � ri D .�r{�1�-t/ - - Date-�:(�Z��ApPlicont`�uGft-/�J-•` ^'`'� c,rr Diamond Bar Z1P . . ., ����n ; . �. 1 __ .. ' 'CERTIFICATE OF EXEMPTION FROM VJORKER$' G� l�-�--� ._ .... . .___._ .. -.. NO:OF BLDGS.- .-'__. '-.': NEnREST - -- .__..-_ . �__.._ - _.__..__._ ...-.- �_ . . � . ! �` �� �COMVENSATION INSURANCE'-• � - SIZE OF lOi NOW ON LOT i � CRO55 5T._ � � (Thli'secHan need not�be completed if the permit'is for one �------ -- ------- �=�- �-�-- -�-�---� �- - �'--�----�, n55E550R --�- ,--� ���-.��� hondred dollors(S700J or lesz,) ,, , .. TRACT BtOCK tOT NO. 3 MAP BOOK ��' - VAGE. PARCEL ' � � � � - --- o�R Bramalea-Limited - -- No.850-1001 "��"'� "'"P ; f(-3 /I -3 , so as'o be�coma s'ub'c�4o he WorkerseCo rk fo�whith ihis NO. : I , Y.. P . permit is issued,I shall not employ any person in any manner . . � SPECIAI -- - -�-- � ----- - ��--- -� -- � �d - . ....__.. ADDRESS. . .... . .. . ' DO�(� CON�ITIONS ' ......,....1 � . :O . , . . . - � . , _ .. . mpensation Laws. - - ... . ... :. � � -. � Date . .` , . . �APPlicani �� . . . ..•�.. ,:. _ ..... CiTY ._C ... _... ZiP. Z 2 __ _ - ...... ..... . :.__. . ___ .. . . .,. �OC ARCHITECT OR � TEL. ' FIRE PRpCESSE�BY ��Q I � ICE TO,�APPLICANT: If, after-making�this�Cerfificala of • _ -. .DISTRICT._ GROUP. TYPE.,. ENGINEER r m B NO. phon,�you should�become subject to the Workers' -� �- � �j ��NeSJT�^ Zj�ljN�E . ' Compensation provisions of thb Labor Code,yoa must forth- ADDRE55 3990 Wes rl P� e Sui te 1�� � �� �-�- /��� --�-/ ��-- - 1f"- � W with comply.with�such provisions or,lhis permit shall be ����� �� --� � .w deemed revoked.-, � • �� �� TE�� STATISTICAL QASSIFICAT�ON ; APT. CONDO. : 'Z �`�� ' � �� '�' ���•�-' LONTRAC?OR BY'dmdl ed Cdl i f. - No. 850-1001' 1'�� � ,_ . - -- . _ LICENSEDCONTRACTORSDEC(ARATION� : � -- - ------------ ---- --- -_-���.- �--- --- �CLASSNp. DwFLLUNITS� � I hereby affi�m that I am licensed under provisions of Chopler 9 ADDRE55 NO ! (commencing with Section 7000)of Division 3 of ihe Businesz and _ �__ __, .. __ _ __. _ -.-...___.�IC. - --- � � . SEWER MAP _ , Professions Code,and my litensa is in full forte and effett. CITY COStd M@Sd� CA. Ct,qSS B � ---- -- --- ----� --�- --�- �� �--�-- �-� . . .. . �.. .. . ..•. .,. : ... BK. pG. i VALIDATION . . . . ... SQ.R._._ NO.OF_._. ..._ NO.OF.._ . CHECK_; . . �� � : Li[ense Number 409610 � � - ��c.Cioii-B'�" ` " srzE STORIES FAMILIES ONE - , , �-, . , , j .` . - . . . .. - R+.• . VAIUATION.__ �,� .�... �� BI'dmalea' �Cdlif. '`• :.", " _' DESLRIPTIONo�wo�i:- ---24C.,,�''_ _ - N�v---� -� - � --- Contr6ctor � Date Ap0 O s /��'� �t/?� ` � 1"Q$Q�A' ❑I am exempt under Sec. --- �$111 1 e-Fami-1 RQS1 d2f1C2- -- '- ' - . - . ; _ _. _ -: . ,� . _ .. ALTER � , • • • ' �� B.6P.C.(or this reoson NeW COfIStPUCt10t1 -- - � -_f. --------=-----•- I -----��=- 2-�---• - -- REPAIR - . „ ' _.- _ �^y,,..,.,'.,�..... , �t����"�,Q.'/�._ . �� EXIST�ING BLDG. DEMO� ❑ 'J�l.�. �P S -1�rr �CIA�S..G+-" ��'N V"r/ . .. APPLICANT TEL. . ..�.. . '��J�,A 6 L L� , ' OWNER-BUIIDERDECLARATION PRMT Bruce L. A6be NO$5O-ZOOL i �NA� , � . --- - -� - - - -- ----- -� - �- -- ....DATE_-L�Z'c��.' - --'---'.' � i hereby affirm that 1 am ezempt from the Contracror's License � � " ' ��a7 1�"�7 U Law for 1he{ollowing�Ye6son•(Setlion 7031.5,Business and ADDRESS 3151 Airwa Ave. N. C ta Me FINAL�` " �` � "'• i - .• 'Professions Code):. .-'-._'- -.-'...-_. . .--'.. -. ---- PResenlT .. sY.. _ . __ ._. ,'.- ' �--•- - . .� I, as owner of the propeny, or my employ�s wiih __-- LOCAI N .. . . . ' _...--'- -.-._... . - -��-- i ;^�8 Q��'�� :.. _ .ra es as their sole com enwtion,wijl do�fie work o�d - CONTRnCTOR � � NO. � , ^ ^~' �� e � • • � 9 P I the structure is nol intended or offered for sale Seciion �� j �- - 7044;Business and Professions Code.--- MOVING---- TEC------�- - ..� 1,os owner of the property,am eadusively tontmcting `--- �-�- � - with-licensed controcfors to construtl ihe project(Sec-. . - ... .--. .- -..._.-- - . .'-'- -- ------�--'---. ....i . . -' --- � . . �. �- - �--- ADDRESS �tion 70J4,Business and Proiesslons Coda). .� �. .. � •���,��. . .. . RE�UIRED- ..70iAL SET6ACK FR _ i . ___ ', .,_:. ' '' �.� -� "�"�"�CONSTRl1CTI0N IENDING"AGENCY-"-----' '"�--- SET BACK �AR�� �H�� � PROP.LINE WiDTH - - � � � I hereby affirm that thera is a constrvction lending agenry for �gpNT , , � i - . �� . " � -�1h0 performante of Ihe work for which Ihis pe�mit is�issued '�-- -P.L:�-- --� ---' ` '--'--- ----...--- -- -- ' .-.-.. -�--- .-. - ''.'. ---. -'�--�-�'�- ,� - w `c!'7 (Sec.3097,r�.e.>. s�oe � _ �8.6 9�8 6 -- �oronto Dominion B�nk- .._ - -... e�. , -- _--= . �. ._ . � - - � Lender s Nome�� Sa-nsame-�t S�i�e 789 �� . �� � , .. : ! .�Lender s Address a, CA 941�4 .--- P.G Fee S - /�_ leeuance Fee^_.���'�`�'I mn.w viC N��--- -- �-`-- - �� � .._ ��. �...' -Sa�� Fransi:sc � ." - ' 3 � Perm r Fee _Lcertify.that I hava reod this application and stafe.thot the � 7S ' _ i . - above information is correct.I agree fo comply with all County Invest�m�on Fee � •'� � _ordinances and Stata laws relating�o building consirottion, 5��� b�� � � �•� ���_ ,,. ___._. ._._.9.._.._._._.__.__.�___ 7owlFee- .�_ , -LOMA�Perm:M-'_.."..' • � � and hereby outhorize representatives of this County to enter �� �'�-� -�`��` ---�-- �-�-�-�"-� `�' opon Ihe obove-mentioned properry f r inspeclion purposes. . , _�, � '� ., .,, , , . � -- - -- -- -- y��✓ __�°�"�h- 3s�--- —.. __._ _._ ..._ .. -�---� --------- --- � LiJ � ' SEEREYERSEfOREXPLANATORYIANGUAGE _ '-.... iqneNre ot Applicant or Agent ,. _ ..,. pete._ """' _�__'. _.' 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