HomeMy WebLinkAbout1598A 1599A (9) � WORKERS'COMPENSATION DECLARATION � - � �� � Il
_ insure oraclertifica�e'ofWorkeseCompenstionlnsoron�e,o � APPLICATION'.��OR BUILDING PERMIT .
a certified copy the.eoi(Sec.3600,lob.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY
. Po❑licy NoC.rT T/n�t�r(6Qn5 77_R 7 S,fl�}��_F�R BUILDING
Certified copy�s hereby fumished. • FOR APPLICANT TO FILL IN ADDRE55 �3�-�� �'�r'x"'-�� �f'
DCertified copy is filed wilh ihe county building inspec• BVitDING �,v
tion de orfinent. ' ADDRESS 236SI Palomi»o Dr. iocnuTr � Ge�.-%�
NEAREST ' /� ��
oo�e � Applitan arrDiamond Bar z�P 9.I765 cRosssr. a��
� CERTIF ATE OF EXEMPTION FROM WORKER ' NO.OF BLDGS. I ASSESSOR
�- � � COMPENSATION INSURANCE � ' StZE OF LOT nIOW ON LOT MnP BOOK PAGE 7ARCEL -
(This sec�ion need not be completed if the permit is for one Zg�26 � use zon+e +�P .
hundred dollars(5100)or less.� TRACT BIOCK • LOT NO. 9 - NO. }
owNezJoseph Maudlin No595-3726 � svean� o.
1 ceriif that in�he erformonce of the work for which this coNoitioNs O
- Y P Di$IRICT GROUP TYPE FIRE PRO[ESSED BY U
permit is issued,I Shall not employ any person in any monner� CONST. ZONE {� �
ADDRESS
so as io betome subjecf to�he Workers'Compensation Laws. � � , /1
Same z�P !o �.� i ��-���✓-.� O.
CITY STATIS11CAlClASSIFICATION APT. CONDO. U
Dote� � Applicanl qRCHITECTOR$, Sca3dach TE�� W
NOTICE-TO APPUCANT: I(, after making this Certificote�of ENGiNEER �NO. CtA55N0.�DwElLl1NIT5 y
Exemption, you should become s�bjecl 10 the Workers' Z
Campensalion provisions of iha lobor Code,you mu51 fo�ih- qDDRE55 � SEWER MAP —
with comply wi�h such provisions or ihis permit shall be {, �
deemedrevoked..- � � CONTRACfOaASiSIDd—KOOl tid.�SB-729I � BK. PG, VALIDATION .
- IICENSEDCONiRACTORSDECLARATiON � 1526 East Washingt0n 81.� � � �
I hereby offirm Ihol I om licensed under provisions of Chopler 9 ADDRESS NU. ' VAWATION -
(commencing with Section 7000)of Division 3 oi the Bus�ness and � � ���, -
� Professions Code,and my license is in full force and effec�. CrtY � CLn55 5 . . -
` 260090 BI (,'6j so.FT.264 O.OF NO.OP CNECK ,
LiCense Number ' Lic.CIa55 � SIZE STORIES 1 FAMILIES ONE
��p�,� Alam patfo cove N�, s
tomrottOr � !l� 6{e–' � '�.. DESCRIGTION OF WORK� ❑ - � � � �
� I am ezempt from the litensing requiremeni�s os I_a�� y(L�R FINAL q�qt.
. - licensed archirect or o�egislered professional engineer - ❑ DATE � G�+ •Y � �1 �9�$A
. acting in my professional [opocity �Section 7051, r+A. CO. $td. N25711625712 REPAiR ❑ '
Business and Professions Code). '. USE OF � SFR - � � FINAL #� � � �2'� �
' . � EXISTING BLDG. DEMOL �
Lic.or Reg.No. � . Date • APPLICANi ,E�. ejr , . I_•.•�1 b 2 4 �
�� OWNER-BUILOER DECLARATION � (PRiNT1 • NO. _ .- �•'e •� (�2�4�
IherebyoHirmthollomexemptfromtheConlractor'sLicense qDORESS1S26 East Washington Bt, �" � � '
- Law for ihe following reoson�Section 7031.5,Business and �/;/, �,rr,v �,,j 7 ��. 0,Z,� 8_8,�
Professions Code�: � � FResetii ��� . . �
� I, os owner of ihe property, or my employees wilh ADDRE55 �
wages as their sole compensation,will do the work and �OCALiTY
- � the structure is not inlended or oNered for sole(Section ' }J� $Q 9 f{
�oaa,6usiness and Professions Code). rnOwNG TEL.
� I,oi owner of ihe property,om e.dusively controtting CONTRACTOR NO. , -� #� � � � �
� with licensed tonlrattors to consrrucl the project(Seo � aDORESS
tion 704A,Business ond Professions Code). � ' - � • •3�,5 Q
- � REOUIRED TOTAI SEiBACK FROM Ex15T. '
� CONSTRUCTION IENDING AGENCY � 5Ei B.4CK YARD HWY PROP.lINE H'IOTH -
I hereby oifirm Ihat Ifiere is o mns7ruc�ion lending agency{or FkUNi . •I°�•3 7,5,��
the performonce o(the work for which this permit is issued P.i.
(Set.3097,Civ.C.). � sioE � � 0 2� 8"8 2
P.L.
Lender's Name � � �
/ qt `'l
. lender'S Address P.C.Fee S �Gi.� Pe.mii fee pc�`v � .
I ceriify thot I have reod this applita�ion ond stote that�he ' � issua�ce Fee 1•�� � �
z . above information is correct.I agree to comply with oll Couny i��esr�ganon fee � J d
, ordinontes ond$tate laws reloling lo building[onsfruction, Toiol Fee J 7'�
9 . and hereby authorize epreseniolives f this Coumy to en�er- _ - I
0 on the a o e•m �io propei�y inspeclion purpases. , � �
i � � .� SEE REYFRSE FOR E%PIANATORY LANGUAGE ��i
� S�gnature of Applican�o�Agen� c��� . , " . . .. . . . _ ' �I
�
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