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 . I j ' �- 'C � i.�1
I�� , , :. �� � �• � I T I ..._I'-'____- "' - __ I "''`'_ I r �1
. � _ - -- - - �' � `
, �: I� ;
�: �.
� I� `'�-r" � � ' , I � I � I --
< <. � � . � � ; � �_
�, : !- � � � , - .., .i _ �� �.� �
c ti� L, C � `-� . � . � . I . �• ��. o I =
I �- f _ � .a :� , ::
� r- i ;� I i � � � � , `
\ � ,. �_� : �
S,1. �,` f I I I , ` I • L�
� -i. .
1 . �t , .•� �
. ..... .. .. ...- -` - - -�I --`---•-�-- ---- -- �� - --_,_I • �,- � ---..._.:-• -_-- ..L'-- - •-, ---- •._:�._ . . -- --- -�•- - — -
I � I � I I I :I' ; ! i �:�i�- � `I I, I � I
. � �i� , �� ; ..�: � :I
I .�� I . I:_, r �{ ' i �, ! I
I I I �; .. I �.. L"I .^� ��' � I
I I . �' . I I ' � " I �� ' �
I � ' i I I � I I V.'i � �. I,
I I 1 v I I !
I ' ' I �~'� ' i I;' � i
I ; I � j I I � (i^ . „� I �
� I i i � � � �._{ � i--+ •�F�.. ' �.._, _.
I I I F? i � I�' I l: I +-j i;• � _. � �:3
� ti�{ j ii. "� I -• I:� ,�� . I � iil
I i 1•-i I I�� 4i' ;1 ./ .., i I ��i
. I •`.' ' : ' : ��• ;7- .� ^�
; i �• i : I .l'y' , j "1. :? j� . �• I I �c,
I I I " I r., . I :-: i,' � i
I ! :.' '• I '� 4�' � •,1
I I � � i :� :�' .:�.' I l. � r
� I I ,:- I i -- � I� . I r:. •�; . :, :j�_, I �. +
i � � j' ► =� i ' � � ;; -1`'. � `'.i '�'" �� ' I
� � ' � i-- I ; c:_ � � �i �� ; '
� � I - � ! I I
i �, I I
I i I I I ! I I � � I I
i I I ► I i � : i I , I � ! ' i
I � ; � , � � ' ' ►, I � ; . � . __- ����' _ �- . - ; ; - � � .. . :. : = -. � _ - -- . � .
; i ; ; � I � � , �� ;. . , . .. .; _ - _ �' _- . - ,
� : i � � � ' i i ( ;. I � , . , .._ , . • - �_ � .. _ _ _ . < �
i j ; ; i i � i i ; I � i • ; :. . . ;, _ .. ' . � �• .: _ .. .... ' ��-:: _
I � .i i � I I � I j i � � ' � � - / .,. - _ . • ' ., .. ' .. - � '.n ' -
, � I . ' ' ' ' --. . . r
� ; j i I � i I i i �' I � ; ` -� : • ' ` ` •• ; .. - . � - ' -- _
` � i . . i i .. ' � i !r. I � i . • _ � ' � „ ' �: ... i _
I � ' � I I � � I � - � '• . l,. . i• _-
! � i i I � I � ! I l: � r. _ i
. . " ": .
. . . ; I : : 1 r.1 i• - �' � .. �
I : . . . ,. • � ' \�_ .� '
I � I � I I ' . � e. - � . . .. " . (1 _ � ,. ..
1 � i ( I I " , .:'• _(.+ , ., •� - ti:,- �
I I _ i .. .. .1:. � � _'' ^ ` ~�• _
!� � . � I � I I C� . I . �. ,-� ' 4. , ` ��. • � _ _ ` !1 _ - _
I � I I tr., I ". _ '. .,. _ c - _'' C��. C�: ` � :.= ^'
I I I . ' I � � .-1' _ =' � ' � ^'.i- = �' b:� _ tii ^ � ;._ ' ';"� - y .
I • ' c: � .. �. _ . `� �� :'_ :i a = :' �- ` �"' = r. `' i,� O
� " I p - ~� C' �� ~ti � F� i v.� �i �:��� �'�ti� �` ii ���
' �- . ' (1 `� �?, � �� . � �'`;� <i � k w�'�ti �L � _=
' . i � ` ; �.. j � �' ��^ h� V T"H �ti �..�. �1 - C)!�
. : . I � � n � N : � ' •�`C ' �� C i `� vl� ,^ �(1+-� -_� tr _. .
�- �.n �: `D '� tr,', � `�•�-�e•�"'a 4• v��
.. ,
. u . c c .. . . } . . '�'� . c:. � ..:�: n �� �