HomeMy WebLinkAbout0890A 0891A . .. .--- ------- - . _....._.._ ._._._
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WORKERS'COMPENSATIONDECLARATION .. . . . ,." .... . ... . ......... ......_...._ . _ _ _ .... .,; ... . .. -- -.--' /
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, I.here6y o(firm �hot I have a ceriificate o(consent to self - � �J
insura,oraterlificaleofWorkers'Compensation,�,�,o��e, APPLICATI�QN � FQR.BUILDING -PERMIT � -
or a ceriified copy thereof(Sec.3600,Lab.C.) ' �� ' � " � - �� � COUNTY OF LOS ANGELES BUILDING AND SAFETY � �
PolicyNo.61WETX799aom��y� : _
�Cer�ified co s here furnished�� BUILDiNG ;`/`/� Y. (Yi A
❑. PY' �' FOR APPLICANT TO FICL IN ADDRE55 �Y'y L ✓�L�.�-�C2v
(� Ceilificd mpy is filed with ihe�count building ins eo- / BURDING �
J�(� lion depar menl: � � ADORESS 24419 �
Da�e��Applicont � CiTV Diamond Bar Z�p � LOCALITY ' �
' CERTIFICATE OF EXEMPTION FROM WORKERS'' � �� - - �-� - :--�� - NOr OF etoGS. � � r�nReSi.- .. . . __._ ___ _ . _ .__. „__ ..
" � " �' COMPENSATION INSURANCE � S¢E OF l0T i NOw ON LOT CROSS 5T. ' � �
(This�section�need no�be comple�ed if iha permit is for one / - - / ASSESSOR
hundred dollors(5100)or less.). ;. . TRACT ✓ BLOCK LOT NO. '�J Mqp gppg � � � FAGE PARCEL
ow�R Bramalea Limited No. 850-1001 ���Qj^� ""^" 1( y
I terlify Ihat in Ihe performanca of the work fo�which this � Np, f I y �• :}
pe�mif is issued,I shall not emplay ony person in any monner 57EGAL � � - -- � - -� 6.
so as fo b�ecome subject to Ihe Workers'Compensation tuw:. � Aooaess�-�-3�5�- A1 PWd V �- " """" ��J CONDITIONS Q
. . , u
_ - - .. . , .. .. .
Date � � Appliconl . .. .' .. . GITY. .. ZIP _ ' .- - �
.� JICE TO APPLICANT: If,�of}er moking this Certificofe oF ARCHITECTOR 7Et. _ DISTRICT GROUP TYPE : FIRE PROCESSED 8Y
�nption,'you shouid 6ecome sobject to'the Workers' ENGMEER NO. �p T: NE �O
/ f� v
l:ompensation pravisions af�lhe Lobor Code,you m�st(orth- 3990 We � P� .j(� /�3 ur
ADDRESS a
ith comply with such provisions or this�pe�mit shall be � .N
deemed�evoked.. ' .., .. � . TE�• 7 STATISTICAL C1A551FICATION AP. CONDp. .,Z
' ' CONTRACTOR NO.F3rjO-�OOI .��
. .. _ _
UCENSED CONTRACTORS DECLARATION ' - - �-LiC. -- . an55 iv0. � DWEiL UNITS—L
n
I hereby offirm Ihat I am licensed�nder provisions of Chop�er 9 ADDRES ryo.
(commencing wHh Sec��on 7000)o(Division 3 ot the Bosiness and _._,_ .__ _���. SEwee hwa �
Professions Code,ond my Ikense is in full forte ond effect Cit�' CL455 B � - BK � � � ' - � ' � VAIIDAiION -�
50.iT. NO.O Np,OF___ CHECK
�ICenSeNUmbef '- A���1e � Li[.C�a55 g $IZE STORIES� FAMILIES� ONE . , . - ,
C� � .vawanoN _
NEW _ ',
' BPaffld�Ea'�Ca��lf�. ' '�, --� -� DESCR IQN FWORK- � -���' - �/�/ � �
�
Con�roUor � Daie ' s ,��� � � �G E 9.0 A
A�D
.._. �
I am exempf under Sec. �� • � • • � . . ._
. ' . . ALTFR � . • • •G�
B.BP.C.for this reason NQW Constructi o REPAIR ❑ s - ' -"- � e?(�.',(��
. .- � 1 .. . Oafe: E IST�ING BLDG. DEMOt ❑ • � J
• n;;�CL,�.��c'_._ ��
Sinnplurn ,� "' '-�'' APP�ICANT TEL. FINAL � ..�
OV NEf1-B IDER DECLARATION �RiNT NO. - _ DATE �- -- � � -�� -- -
1 hereby affirm ihat I am exemp�from�he Contracror's license qDDRE55 3151 Ai rway Ave.,N� COStd Mesa � ���r 0—8 6--�
- law(or the follawing re6san�Section 7031.5,Business ond FINAL� � � � ' � � ' .
Profe'ssions Code):� " ' ' - - pRE NT 8y � - - � •
'�] BwiowG .
5 I, os owner of Ihe properfy, or my employees with ADORESS
...
wo9es as iheir sole compensorion,will do ihe work and � � - .
the struclure is not in�ended or offe�ed for sole(Secrion ���ITY
� - 7044,Business ond Professlans Code). - - ��-� -�-� MOVING'� � �-��� -- � -�--�-- TEt. -- ,-- � � � � � ��= � • .
C'�9 1 A
I,os owner of the property,am ezclusively conlratting CONTRAROR NO. � � , �
�._ _ _... y.�w • • o ,
wuh ficensed mntrocrors to�consrrucr the Project(Seo- .. .- - - -.--.-. - . ... -. . - � - - --. .. . . . . .
tion 7044,Business ond Professians Code�. ADDRE55 , c ,r ,
- - � � REQUIRED. .IOIAL SEiBACK FR M I I �G a G O
- CONSTRUCTION LENDING AGENCY ' '� "� - - 5ET enCK YAeD� �HtVY PROP.UNE WIpTH �� �� �� -
I here6y aHirm thal�hera is a tonslruc�ion lending agency for pkONT � . ��;,�Q G�_ '
_ i. �
..Iha performance of�he�work(or which Ihis permit is issued �- �- v.L. �-- . . . .-... .... . .... ....'- ''--- .._. . _ _ . . .--- ----.._._....._. .._ _..
($eC.3097,Civ.C.). SIDE -
� 0820.—&6
m _ . -- - -. . . _.. _._..._.. _. _._. _ _ . __ --
�.._
Lender'sNoma Toronfo Dominion�Bank� - ,
`? 144 SanSome St.�-SUi te 700 - r.c:rea s - .� 7:- oe,�„��Fe, vr77�S� �DMA Rel.p
, .
Lender's Address � �
I.certi(y ihaf I have read Ihiz app icatian ond state of tha _._. _ . __ .. ._�.-rl� � Issuvnca Fee. �0'�� . LDMA P/C N �' -- . . �. �.. .
. .._' . ._. _.
obove informalion is correct.I ag�ee ro comply with all Counly Invesnganon Fee (�p
.ordinancez and Stafe lows relating fo bvilding mnsiruction, ..___ To�ol Fee� �O p• � L�MA Perm.M -� - �� � �
_. _._ .—.__.__ .' ._. .
and here6y aufhorize represeMatives of this County to enter - ��--�� - � - � �� �,
apon Ihe abov -meMl ned pro rl f r inspetfion porpos � .
. .. _ . . . . ._ _ .. .. ..._' .' _ ___ _. _ _
- SEE REVERSE FOR E7fPLANATORY LANGUAGE �� !
-._... ar of Appll Agen . _ ._'Dofe" _ . _ _.._. ....' "_ ' ' . -._... . _ . ... . ... . .. .. .l. :
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