HomeMy WebLinkAbout1665A 1666A , . _ .... .. . _...__ . . . . . .. .. _..
WORKERS'CO�f�.PENSATION DECIARATiON � � • � ' "' � � - ��
I hereby a(fiim Ihnt I have o cerlificale oF�o�,��,,o,e�f � � �-� -�--APPLI�CATION ��FOR �BUILDING �PERMIT � �
insuTe,or a ce.riificate of Vlorkers'Compensotion Insurance,
or a cr.riiffed copy�hcreof(Sr.c.3800,Lab.C.) � .
COUNTY OF LOS ANGELES BUILDING AND SAFETY
PoliqNoPC A6f1755FComp��n[1vc.�Tnd�+mni tv Co � �� -
CP.11ifi�[�CO s hereb Furnished. BUitDiNG
❑ PY' Y FOR APPLICANT TO FILL IN � 3.� �
ADDRF55
OCertiFird copy is filad wi h th ouni h i inipc- pUILDin:G � ��
r dep rimenl. � ADDRE55 24433 St. Ives Ct.
Date n�Pi��o�f CITY Diamond Bar Z„ ioc>,urr
---
C RTIFIC TE OF EXEMPTION ROM WO ICERS' " "' " ' ' "' ��N0-0F P.lDGS. -�- , IVEAREST . .. . „ _ _ _ ,. _, , :
' O:MPENSATION INSURANCE � . SiZE OF LOT NOW ON IOT Crt055 ST. � �
(Thiz settion need not bc completed i(Ihr,per it is for ene! " 7RACf 42 �l(7 BLOCK lOi � . l�j��� aSStSSOR . � � � � �
hundred dollors(5100)or less.) r 1.`.nF BOOC PAGE� PARCEL
owneaCalif. Communities InCyE�" USE��E o�> ��_ �
I certily that in thP performance af the work for which this - �` - }
permif ii iss�ed,I sholl nol employ ony person in nny manner S�ECIAI a I
so os to become sub'e�t lo ffie Workcri Com ensotion Laws. ADDRESS 318� A. Airwa Avenue�
I P n2dY-+"[� CONDITI045
`'-- atr Costa hfesa ZiP 92626 _ u
Date. . . . qPplicanr ' . . . - � y.
'�TICE TO APPLICANT: If, af�er makin this Cenifico�e of ARCHiTFCTOR TEL. ' I
9 , .DISTRICT G4(JUP NPE FIRE_ . .FKt(XESSED BY �
�nption, you should betome. subject�to �he Workers' ENGiNEER NO. _ �� ,[J CON 7 NE
�ompensarion provisions of the lobor Code,you musr forth- ��1]O�:Q.8.92660 /`"J � . � �'4' �
wi�h com I wiih such .ov�s�one or �his neoRess3990 idesterl Pl. rr .
P Y p permit sholl be" TE� �- �
decmed revoked. , N� STn7iS7iUt CWSSfICATiOY APT, COYDO. �Z
CONTRACTOR ��.,7i
LICENSED CONTRACTORS DECLARATION• � ��� C1A55 hp. Dv.�ELL UVITS�
I here6yaff�rm tho�I om licensed under provisions of Chop�er9 A�ORESS ryp393�OI
(commencing wi!h Secrion 7000)oF Divlsion 3 of the[iusiness and . . . . _. . , ��� SE�S�R�nna
Pro�ess�ons Codr.,and my licr.nse is in f�ll iorce and ef(ect. C1n55 B 1 � VAIIDATION �
NO.OF NO.OF . CHFCK CK. PG.
�i[enSCNumbef �Q�7n� �iC,Closs ` STOR'ES FAMIIIFS ONE . .. ;:� L Q j f{ '
VALUATION
�. �...�� oa��� � �FSCR�PT�ONOFWORK ' _ � . � 178,900.00 ;% •�� -
Conlraclor � NEW O = • • •
ADD
�I om exr.m under Sec. --S.F.D.� — P13rt 2 q�TER Q I •�l J�.�?�.
B.SP.C. thi reas RFPAIR.� . s . . . -
Dale. � USE OF ❑ • s=!J 1.���;.
EXISTIIG BIDG. CEM1+.OI
.._ Signature , �. nPRiCArar TEL. FIHAL •rl��1 J-?7(?
IV1vER-BUI ERD LARATION f��vi� No662-3700 pATE �����S7
I hereby affirm tha�I am ex p�irom 1he Conhactor's License � � ' ' � -'""�� "" �— .
law far Ihe following rcason(Settion 7071.5,9usinr.ss and /DDOE55 2 2 FINAL �� � � '
' Professions Code): " "' '' '� " vHeStrvi B - � �
�-7 BUILUI!.'G Y �`
` I, os owncr of Ihe propr.rty, or my employr.r.s wiih P�D4E55 _ ,
1 wages ns ihrir'sole compensa!ion,vii!I do thc•.vork cnd .
� ::iv'n
fhe structure is nof in�endr.d or oiiered(cr sale(Seclion ��'��T� ..- � .
70A4,Businr,ss nnd Professi0n5 CodB). 1.'.OV1NG ' � ' �� �TEt. , ,,'� i. • ° • •.� .
� I,as owne.r Cf thc pro�efly,Om exCluSivCly tonlra[ling CONTRn�'f04 NO. ' � " _ _ '
...>'. �\ ...� ^
�with litensed mnrractors ro cons�ruct the,projen(Seo- ' -- �. .. . ' . . '' ..:I �7�'(�Q Q
iion 7044,Ausiness and Professions Code). �DortE55
- RtQU:REU fOiAl SEIGACK FHC.•l� i � ° ^ �C'.;�.G�l L'.
' CONSTRUCTION IENDInG AGENCY � � SET oaCK YARD HWY' FROP.IINE WIOiH � �� � � �� �� � �
I hereby affirm Iho1 thr.re is a tons�ruction lending ogency ior f ROYI �`U�`L�J �
�he pr.�formance of�he work(or which lhis permit IS ISSIIPfI ' P,� , �
(sec.3097,Civ.e.). sioe _ . . . .. . .
._ . . P.L. '. ' .
Lender's Nomo �� ' , �� �� �
nQ r LDMA Re�.M '
Iender's Address �� � "� P.C.Fee f • P-rmi�Fec � /� /+�7� I. . . _,
I tertify ihol 1 hovc read this applicotion ond sb�e that Ihe ��y9c .�.�.� Issoance Fert /�•U� LDMA P/C M ' . � ' ' � �
nbove inlormalion is torrecl.I a'ree fo comply wilh all County ����y„qoiion Fee �
ordi nnces on s reloting to building construcrion, _ Taml Fex ��J�O� � �lD.'A,A Perm.N '� �
d ereby au ho' ' s of�his County io enter � � , � �
n he a ove eniloned� oper or inspecti purp es. � �� •
' - ��� SEE REVERSE FOR F%PUNIITORY LANGUAGE . ,
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