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Home My WebLink About6789A 6790AWORKERS'COMPENSATION DECLARATION PLAN 600A ihsureb or a certificateofWokes'Compensation Insuranent to ce, APPLICATION FOR BUILDING PERMIT or a certified copy thereof(Sec.3800,Lab.C.)COUNTY OF LOS ANGELES BUILDING AND SAFETY PWCC253824 A Policy No. ompany INA BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS © 1 Certified copy i i filed with t bu'c BUILDING lion depart pf ADDRESS JOU lummitridge nriLOCALITY NEAREST Date Applicant CITY Diamond Bar. zip 91765 CROSS ST. CERTIFICATE OF EXEMPTI FR WORKER' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT —0—MAP BOOK PAGE PARCEL This section need not be completed if the permit is for one US QNE MAP hundred dollars($100)or less.) TRacr 42571 BLOCK LOT NO. T No. 1 TEL, SPECIAL 1 certifythat in the performance of the work for which this OWNER No.529-8170 --O)o/ CONDITIONS P DISTRICT GROUP TYPE RE PROCESSED BY Ca permit is issued,I shall not employ any person in any manner ADDRESS P.0- BOX 350 CONS so as to become subject to the Workers'Compensation Laws. p CITY Brea, CA zip 92622 VVV s licant STATISTICAL CLASSIFICATION APT. GOND . ate APP TEL. 8 ARCHITECT OR TSLOTICETOAPPLICANT: If, after making this Certificate of ENGINEER NO. — CLASS NO: DWELL.UNITS Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth-ADDRESS 10841 S.Paramount Ave., Downey SEWER MAP with comply with such provisions or this permit shall be TEL. deemed revoked.CONTRACTOR Owner NO, BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.VALUATION commencing with Section 7000)of Division 3 of the Business and LIC. 1 [ . 67 8 9 F Professions Code,and my license is in full force and effect. CITY CLASS SO.FT.NO.OF NO.OF CHECK License Number 54648 Lic.Class B1 SIZE STORIES FAMILIES ONE N'° ` ° 2 1 s Contractor Date DESCRIPTION OF WORK New Single Tamil NEW i rt d:16.8 C ADD I am exempt under Sec. with attached garage.: til i U•k C x P ALTER FINAL B.&P.C_fDr t r o REPAIR DATE f / 7—f7 i l ?—J 7 USE OFEXISTING,BLDG. N DEMOL FINAL ` r°Jr 7_ Signature APPLICANT TEL j I\ ER- UI LA PRINT)M.S.BYOCk & SODS N0.529-8170 1 hereby affirm t at I am exempt from the Contractor's License ADDRESSP.0.Box 350, Brea, CA 92622 O Law for the following reason(Section 7031.5,Business and z v i v F+ rofessions Code): BUILDING I, as owner of the property, or my employees with ADDRESS a 1 wcges vs their sale rnmnensntian.will do the work and the structure is not intended or offered for sale(Section LOCALITY I ` iFXJ7044,Business and Professions Code). MOVING TEdFROMI,as owner of the property,am exclusively contracting CONTRACTOR Na o 7 i I.U L 6 with licensed contractors to construct the project(Sec- 7 9 tion 7044,Business and Professions Code). ADDRESS t REQUIRED YARD HWY TOTAL SETBAC CONSTRUCTION LENDING AGENCY SET BACK PROP.LIN I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L, Sec.3097,Civ.C.). SIDEP.I. Lender's Name None Lender's Address P.C.Fee$ Permit FeeIcertifythatIhavereadthisapplicationandstatethattheIssuanceFeeaboveinformationisorrect.Iagree to with all County Investigation Fee j ordinances and Stat laws relafin it ing construction, Total Fee 711 I and hereby out ri a rep sen t is County to enter i upoa -m ntio r/r rspection purposes. 11 ggayy gp qq 1 t'C,y SEE REVERS FOR EXPLANATORY LANGUAGE igruw a of d p Hca t eni / Date s r Y Q nI _- 9-iII o i 00 Q W C e i 3 a I i 6 I E, Lq 1 l Gob I i v I YU I t ZL I i ie a q r I i i I i a' mCLCL4 nf I e C < jf ct JtII I II I . I I i 3 n .w. ”` •. N -j P.. w =.0 % ` ' "'tea' e' u oz 2 ry c nzliiI: s•i y O J1 i O n -t^ \"`'-. it 1 s A Oe `s,'_.•:.,...O.O w .'". s.,, ° ^lam n 1 V • I G -i v Z., w S tin.(n L ^.. n Vr,. '+wi ( b ^ O O 0 'C ' •. ti P .'` 71.