HomeMy WebLinkAbout1596A 1597A (17) 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 - � /
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