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HomeMy WebLinkAbout1188A 3162A 3163A (5) WORKERS'C0.IPENSATION DECIARATIOY ' "� I here.by alfirm thnt I hove o certi(ica�e of consent•to snlf • APPLICATION FOR BUILDING PERMIT insure,or a certiiica�e of Workers'Compensaiion Insurance, ' or a cerri(ied copy rherr.of(Sec.3?00,leb.C.J COUNTY OF LOS ANGELES BUIL NG ND 5 roi�cyNo. CAf,9454ompa�Y FATRM(1NT e Cer�ified co is hereb furnished. eu0.D�nG ❑ PY Y FOR APPLICANT TO FILL IN ncr.R�ss � Ce�tified cepy is filed with the caunly building inspec- BURDiNG � , � � i. 1i0n�epprlfr�ppl. ACDRE55 lOCA1tTY ' /�/�5 NEAR�ST Da�e Applicanl CITY ���� Zip p_l�� CROSS ST. .CERTIFICATE OF E%E�d�PT10N FROM WORKERS' k0.CF BLDGS. a5SE55C� COM�PENSATION INSl1RANCE SIZE CF LOT NOW ON IOT MAF pppK PAGE 7ARCFL (Th�s seclion need not be complefed if ihr,permit is�1er one 33537 � 3 U"� N� M"4F S_ 3 3 hundred dollors(5100)or less.) iRACT AIOCC LOT NO. `��� NO. � ICL ���. S�'ECIAL I tr.nify thol in 1he periormancr.of the work for which this O\VNER �O. OC, C' CO'�DITICNS f}i. �e����'CteL���p�'�J U'S1R'CT GVOVP TYF'E FIP� F�p�ESSFD BY O permit is issued,I sholl not employ cny person in any monnei qD�FE55 Q � �� ,�j CONST. ZON� V so as to 6ecome su6jett to the Warkers'Compensalion Lows. n��L S V`� 7 c,,,. Diamond Bar Z,P � � Do+e Applicanf $iA71$IICAlQA55iFi��c�qqq llp^l APT, NDp. O �ICE TO APPLIUNT: Ii, after making this Certifico�e of nFCHIiECT OR TEL. � L� V nplion, you should be.come subjrci io the Wcrkers' �NG'�FFR � NO. QP.SS NO. DwT.11.UNITS '/—� u� Compensation provisions of the Labar Code,you must forth- �� wilh [om I wilh such ADDRF55 SCV:ER I1,AP decmed revoked. P�ovisions or Ihis prrmil shall hn pIERAfARINI 861-63 VALIDATION ` TEL. CCNTRACTC4 NO. EK. f'G, LICENSED CONTRACiORS DECIARATION LiC. I hereby afiirm tha�I am licensr.d under provisions of Chap�er 9 nDD4E55 n0. VALUATION (commencinq wiih Sectian 7000)01 Division 3 of rhe Businnss nnd ���, + ',.1 � n�r. Professions Codr,ond my license is in full force and elfec�. Ciiv CIA55 — 5 �� (J (� 50.Ffr. VO.CF NO.CF Ck�ECK , ��y � � �'�J LitenseNumber 283�24 u�.eio5� B�1 size sTeaies rn�r.�iies eNe ' � NE W � 5 I 6fi2.13 ' Conlraclor PTFRMARTNT paie 7�$f$5 �ESCR!PTION CF\'lp4K i �✓� nco � ��.1 ��� ❑I am ezempt under Sec. A�TE4 � FINAL � �,J � 8.8P.C.for ihis reoson ��PA�� � DATE ���7�—c�!- e��C�'—?J �, USE O� C'.M.OL �ate: � FINAI 1 E%ISTING BLOG. BY ��`�� $IcjnalUle APR�CANT iFl. OWNER�BUILDER DECLARATION PRINT) NO. � ^�� (�C r I hereby affirm Ihal I am exe.mpt irom thr.Contractor's License Law ior the following reoson(Seu�on 703I.5, B�s�ness and �C�cESS , , • • . .j j Professions Codo�: puEcitii ' • � ,c J� � BU:LD'NG I,as owrCr of 1hc property, or my employees wilh ACDPESS wcges as Iheir sole compr.nsalian,will do the work ond . � � ��� ���� ihe s!roctuie is not intend!!d or offered for sale(Sec�ion ��/'��TY . - 7044,8usiness and Professions CodnJ. MOviNG TEI. � � G�.C 7"C.`'. � 1,os owner of the property,am e.clusively con�racfing CCNTNACTOR n70. wi�h licens?d co^hactors to constroct the prejecf(Se:• A�CRE55 ' ' �ion 7044,Business and Proir.ssions CodeJ. liE(]UIRED TOI�L SEiBACK fi7UM f%ISf. �t �3�•1 CONSTRUCTION LENDING AGENCY SEf BnCK YnaD Hpry OROP.LINE vnDrt� ' �� I here6y affirm ihat thera is o tonshvction lending o9ency for f�tUui ►�' � � � ,: � � � � � , the performance o1 the work for which this permit is issued a.l. �Sec.3097,Civ.C.�. sioe ' � • — P.L. � �,��'a�� Lendery Nmm� O 2 'l �r.� $ Lender's Address P.C.Fee f �O�-�_J P�rmi�Fee �v � �V" , • '�O������� n I[erti(y Ihal I have read ihis application and slole Ihot ihr. / U�V v Iseuance Fee �U �� • l , , ' ' � ' � r 9.�1 r�r � obovo informaiion is correct.I ag�ea to comply with oll County in�Psi�9ai�on Fee �7l g o•dinoncef ond S�a!e Ipws reloting to bvilding conslruclion, Torol Fee /��� � �/ Y1 and hereby a�thorize representatives of Ihis Counry to emer . � upon the a6ovr,-menlioned proprrly for inspetlion purpases. Y.i�,y��lJ�� �� A �Sy. i- ' , p"u �r J . SEE REVFRSE FOR F%PLANATORY LANGVAGE � 1 Slgnn�vro ol Appliranl or Aqent Dote , . C� •�a,V o` '�?+ n o c . c � o N e cr?+�j o o n:� ,� n Gl " � o �r. ' c' � [y � ^ii � c �� � � c � ;:.cl r.. gr. : c� c. 'o u _—�'— \ � '� �f-* 1� C: `G� � ^ �l C r l7] v 'v�_ ��^: 4'. (? � l � I � � fi � c.. �, Q'c % - = c. � � I � i' :: �i`� _ _ �'' ^ � � � `' ; _ ` � J �� =; •_ `� `= � I � _ �• ' �• I � . _ � i .�: i �. ,� �� � i :� ' I ,� �� �,_ — ,..�; � �; � �� �, — I� `. I � '.' ; I � ' •i I I ., ? _ I ' � . i r� I � � .—' I 1 i �JS w_ l�\S��i\ i } �►� _ -� ---- �:• I I. ' I ' : `)a C� � �`� � 4 \ t� I� '� �-- --- ---�-- �-- --I -- I I -�' - ---�--- --�--�i`_� '` t,` � � ?. -� � I -I-- � I o� I � � { � . n �� V1 �� I I � „ � -1__ �': �i 1 _._ �I-_'_ . � __I 11 �7 + � �� -_ _ ___ _ /' __�- - ��__ _ ' _ - _'_ _ �" I' �' r7. i� 'ti � �; C a� l\ �� �r' I' I . 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