HomeMy WebLinkAbout1596A 1597A I �WORKER$'COMPENSATION DECLARATION � . � . �f
I here6y offirm tho�I have a tenifimte of�o�5e��,o,e�f , APPLICATIO[lR.. FOR BUILDING PERMIT� 's �
insure,or o tenifitole of Workeri Compenslion Insuronce,or
a certified copy thereof(Sec.3800,Lob.C.) COUNTY.OF LOS ANGELES BUILDING AND SAfETY
PolicyNo rp.46Un{o�fPo�77-82 State Fand
BUILDING
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 �3 3(p -�� � Q
rl Cerlified copy is filed with the county building inspec• BURDiNG
�X-� tion depar menl. ADDRESS2343G Sand Rid e Rd. iocn�irv Ga,....1..�C� �' ../
Diamond Bar 91765 NEAREsr
"Da�e � Applica� � CITY ZIP CRO5557. � �
C RTIFIC E OF EXEMPTION FROM WORKERS' NO.OF BLDGS. 1 ASSESSOR � (/
COMPENSATION INSURANCE SIZE OF LOT NOW ON LO7 MAP BODK PAGE PARCEL
� (This ieciion need not be campleted if fhe permit is for orie � ��/'/ VSE ZONE rnnP �/
hundred dollors(SI00)or less.) ' TRACT �0��ji BLOCK lOT NO. .�.T7 ,�'/ NO. �U���T� ��.
TEL. SPECIAL � C.
OWNER Stephaa Lam No594-2025 Syy�"��� coNoinoNs ' p
'I,certify thot in the performance of the work for which Ihis DISIRIC7 GROUP iYPE FIRE PROCESSED BY V
. permi�is issued,I shall not employ any person in any manner ADDRE55 . CONST. ZONE y�
so os to become subject to�he Workers'Compensation Law:. .
crtr Same zir /D �{',� � � lc�-.i O
� D01e ` Applicanl � STATISTICAL CL4551FICA�ION APT. CONDO. V
' N O 1 1 C E T O A P P L I C A N T: I f, a f t e r m o k i n g t h i s C e r l i f i c o�e o i ARCHITECTOR S. S c h a l d a c h TE�' ' w
� Exemption,�yoo should become subjett to_the Workers' ENGMEER NO. CLA55 NO.��DWELL.UNITS_ y
' Compensa�ion provisions of 1he Labor Cade,you musf forth• qDDRESS SEwER MAP � z
�wilh comply with such provisions or this permil shall be . TE� —
deemedrevoked. AIII7118—KOOZ 74B-7Z9I BK. PG, VALI�ATION
CONTRACTOR NO. '
' ' LICENSEDCONTRACTORSDECLARATION 1526 East Washingt�en Bl. '�
I here6y alfirm Ihvt I om licensed under provisions of Chapter 9 ADDRE55 nlU.
(commencing with Section 7000)oF Division 3 of Ihe Business and VALUATION
tIC.
Pro(essions Code,and my license is in iull force and eHect Ciiv CLn55 E Z 0�0. �
SQ.FT. N OF NO.OF CHECK �
LicenseNumber Classs_o�r SIZE 3Q2 STORIES� j FAMILIES ONE ,
�� l DESCRI7TIONOFWORK Alum patio cov �6ew � s
Conrmcto � � I�'� � �
� I om exempt from Ihe Itcensing reqvirements os am a � ADD �
- � �litensed orchiletl or o regislered professional engineer . AITER � FINAL � �
� acfing,in my professional capoci�y (Section 7051, REFAIR DATE ��a- � I
Business ond Professions CodeJ. USE OF SFR ' � FBIY AL ^, 1 � 'i
DEMOL cw9'J
EXISTING BLDG. ,
Lic.orReg.No. �ote APP(pRIMI Richard Freedmar�;o748-7291 z 1'5�9 6 A - ?-
" - OWNER-BUILDER DECLARATION ' I' / �
I hereby offirm thof I am eaempl from ihe Contractor's License ADDRESS ^r+,�G+� ,�,7 7�� #� � � �2'�
Law for the following�eoson(Section 7031.5,Business and �-«��
Proiessions Code): �Rt��Ni � �..• �.� Z 8 8
� ❑ BUIIDING � �
I, as owner of ihe properly, or my employees with ADDRE55
wages as their sole compensotion,will do the work ond �• • • � z 8$c=i �
�the strutture is not imended or oflered for sole(Section �OCAIITY � � �
704d;Business and Frofessio�s Code). � MOVING TEL. �2� a�8 2
�- I,os owner of the property,am exdusively controcting fONTRACTOR NO.
wilh licensed controc�ors to construct the project(Seo- qDDRE55 � �
tion 7044,8usiness ond Professions Code). . ' �
REOUIRED iOTAL SEiBAIX FROM ex�sr. 3 1 5 9,7 A
CONSTRUCTION LENDING AGENCY SE�BACK YARD HWV vROP,UNE WIDTN ' -
' I hereby atiirm Ihol lhere is o conslruction lending ogency for FUONI �� �i�;� � '
the periormance of the work for which Ihis permil is issued P.L. . . i
, ($ec.3097,Civ.C.). � SiDE� -
,.�. I • •3 1,5 0
lender's Name /� � •3.��S��
S P.C.Fee S ��L. �1' Permii Fee �,J� �� •"•�
= Lendei s Add�ess a �2� 8—8 2
� I cerr�fy thot I hove reod this applicat�on ond sfole Ihat the I:suonce Fee f �sd '
� _obove iniormalion is mrrect.I og�ee to comply with all County Inves�'�gano�Fee -
$ ordinances and S�ate lows rela�ing�o building cons�ruction, . iarol Fee .��.�0�
ond hereby auiho�ize represemo�iyyy��� of this Counry to emer
� upon 1 bove��proper�r��ection p�rposes.
q 1 f OC .��� � SFE REVERSE FOR EXPLANATORY LANGUAGE - � /
Signofu�e of Applironf ar Agent po - . . �
. . . . / . .. . .. . �\\
_ o
.�--� o
..— �•
� T� � O � p o
,o r n� �v p., O C; O S n .
p � 7 n p '�" � �m Q O m �O C
r .F CJ fi ..i". n 'AO ::. 'O � Q
.. T T ff� G �a � 7 P. '.�; j O � 0 O . O
r, p �n � a � o c
r- a 7 0 � a � �r , a �„ �.o � 3 0 �
�.+ C�2 a !: 3 a �o ,c aa o,� o o r� ,w v
>> o� � � c�' a •Q. F� �o 0 0 � .fl� ? , • , r
-'�.Of � �n ` � D '� ' b R°� :< " � ' , � . Z
O 1 �� % ^< � ' H -G . C ✓D o . t/�
7 �Z N OM1'� G. � a � . ^�
0 0 6 Q g ' N- f° . a O
�m � , � a: a+
� m - � .G �0 �o
at _ . - � o o , m •-
D M �' O a �
° 0 8 Q- -+
O 'Z ¢' 'q
6
. � �
' � �p �
� , p m �s
t� �a A 4
o a � o
-�' o o, o
.�, • ,o a m
M ' (y q
. N
6.
�
7
G
C
Q
' •
;
�
• N
. .d
. �
N
V+
� • - �.
� _ .. ��n
' _ ti�
L
- r�
. -� �
. .. c m n
. .. n n,Cy�'•y ^� �� �. -��i �
� o
� � -� � �ro� n��Y �:�� ��'.�� � � o
-' • ��� o 0 0 �.� :.�m �s..a o H� '' n r. 4 �
� - . c'1 y ~,r.o a �� m-~ � �a�•' o« �° `�C 'r =o�...�,.�,�c�'Q' £ O.'�
� �U' Q �n.N°Y� £ L =ti,.� m " M i'" n c � a »� � «.�.� �`r� 3•� O� 3 �
'� � A p � L n ;� n �S!o.`n „N CM"�, p,p.� �_£ e.C� n b i o �� � ^.� S l 7�
N
. , � � � -•E o `�' � o c�°-� ° �� opO^ � �' � r, 5� � a-�` � � � o G
�" � �-.,w « i� fi �a�--, p �o'� '� A o Q
=•'O R iw � •,,,, • �3 O V H 7 .�.. e� ,+� " O � SL;
� K `.p � A c O-� � A O fi:0 e � •G O �Y�Fw�A��.��o O 'D�
� A ^ N a a.o °' �� °p � ` a a w o--�o ° a ^ M ...°,'n "?,� ��' £ m C7
1 v � $ � � o� o s�c' s..� mm " on" A ' � �
A '� 's �-: o` n a,o e� � c-� ° " � n+"a�°9 t�
S - Z ¢ ��"e r^�.y`��.° `° o ' c.." c�� �° °o t..�o•��`e�,«� "� m ,^>
N m f C H O p O.�'O e� L'• O � O,O F �n 3 O_N �4} �^ � w.� O
�O ...O �y'G: .N'O x O F. C�...� r.j ?� 3 3 O � !+ � �. 0 �A
, , � n � • x p o:� O ^ �� A o'e� � o p o 0 A.n`'o'^R �Y o p Q 'o O �� r"�
,1 � � ..'.Cr.`i N O-�' w �� ~ C �^ C�4'£�3 F..A V1�N � T�w:�= O .t m H
. �p . n' �n? Q O O �G C�� w A `'2 � � C p � O
c, O O �. Cr�•3�--.A..� O O Q. �3 Q`.`t ,�, 3 w A ta' m C1 Z �
.: ' N N C F �C O �•io � ^� �^t� t N O O �...�O ca 4.y F A.�" '� n O
1 � �n 1 '^' .^.. �� �.A• o , ^ m m b N �J C-�4a'►.�n � �� ��
u' t� �.. D � ❑
�m1 y � O L�"7� � �.C.r„'-w P .!' 1 U��C`� (A W�i'�e1i�•W lp� p � W�
, . N , O . � `.+.h O . ,� O "' 'L"'� N m D 0 �n� �`a^ II' � �' O
< �`�` ,� N L' n"'p
: � 7� � � K n o p p m 'V C»a K 3 � C"^ '7r N �M�w o�a��'�'F E`'�''a
t o Q� P ��V x £_ `C Q'n
, e�a m !� O a �� v A k A O A � �� i
i . (1 "p� p � j � 0 .z � M�., •���7 • �.+�
, . p ' -� � � O PP� � w !Cj �`-• � '1 ti N
M
{ 7 . �C,p�,;.^
� ' . � � . N . . �� .
-�