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HomeMy WebLinkAbout0958A 0959AWORKERS' COMPENSATION DECLARATION •••;-. , r<:y .,„•• --” - "' -' I hereby affirm that I have r certificate, Comte ns tion Ins to =elf ---- - - APPLICATION -'FOR BUILDING PERMIT- or insure, or o certificate of Workers Compensation Insurance, or a certified copy thereof (Sec. 3800, Lob. C.)- - - -- - -- - - ' Policy No.61WETX799,lompany Hartford Group COUNTY OF LOS ANGELES BUILDING AND SAFETY 0 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING I Certified copy is filed with he tori b ildADDRESSin 'nspec- BUILDING \j- tion department: ADDRESS 24445 East Thunder Tr ' Date Applicant -- CITY Diamond Bar ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' -- -- - - - - - NO. OF SLDGS. - - -- - NEAREST.___.. ,_-_. .. ...._. _. ._....._.._ ._ COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. This section need not be completed if the permit is for one -- - -- - - - - ASSESSOR hundred dollars ($100) or less.) TRACT i BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. OWNER- l - NO.- US,b E MAP i'- I certify that in the performance of the work for which this - !x PJ NO. permit is issued, I Shall not employ any person in any manner - 3l 61. Al rWa AVe . SU i to NN. ? - - SPECIAL - .- - -. p• so as to become subject to the Workers' Compensation Laws. ADDRESS •y- s - - L9QG 0 CONDITIONS C) CITY Costa ZIP.. U Dave - . , -Applicant : , . ;.. -, . . , _._ - - - - .. QARCHITECTORTEL. LICE TO APPLICANT: If, after making this Certificate of p15TRICT _ GROUP TYPE _ FIRE PROCESSED BY - FENGINEERNO. 752-1864 0 jnplion, you should become subject- to- the Workers'`- - CON ZONE Lompensation provisions of the Labor Code, you must forth- ADDRESS 3990 Westerly Pl. Suite awithcomplywithsuchprovisionsorthispermitshallbe -- - - - deemed revoked. TEL. STATISTICAL CLASSI KATION APT. CONDO. y CONTRACTOR NO. 850-1 1, ? LICENSED CONTRACTORS DECLARATION - . - - LIC __. _"___ ._ CLASS NO. DMLL LINITS hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Airway NO. commencing with Section 7000) of Division 3 of the Business and - . LIC. - SEWER MAP Professions Code, and my license is in full forte and effect. Cltt CLASS B --- - BIC FG. -- - -- - VALIDATION 409610 _ 50. FT._ NO. OF _ _ _ NO. OF: _ _ _ _CHECK License Number Lit. Class , B SIZE STORIES FAMILIES ONE G Lia 8 A VALUATION contractor Brame 1 ea Calif Date • DESCRIPTIO F•CVORK PAN 3 ' - NEW © I ° • - I am exempt under Sec. Sin le Famil sidence AD s fid/ ; 8.8P.C. for this reason ALTER 2 C:1 REPAIR 1 Dat- - EXISTIING BLDG. None DEMOL L'20-86-_ Signature All NTi George Vedel l NO. -1 FINALOW I am exempt R DECLARATION% ._ _ - - DATE - - ... _ I hereby affirm that I am exempt from the Contractor's License - - - ' ' Low for the following reason (Section 7031.5, Business and ADDRESS FINAL ' Professions Code):-' "' - '- - PRE ENT By - - - I, as owner of the property, or my employees with BUILDING J ADDRESS i. Awagesastheirsolecompensation, will do the work and - - - •l i 9 the structure is not intended or offered for sole (Section LOCALITY 7044, Business and Professions Code). -- -_ - - MOVING - - - - - - TEL.' - , - - ,r %: ° ... • j I, as owner of the property, am exclusively contracting CONTRACTOR NO. W r,licensed/ onwithBuContractors ndfS to [Orion C the project (set- ADDRESS - - I `'y /I Q" O " tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FR XI T. _ _ _ CONSTRUCTION LENDING AGENCY g - SET BACK - YARD HWY PROP, LINE WIDTH - - -- e (L y' C. 0 - hereby affirm that there is a construction lending agency for FRONT u i [ C -86theperformanceoftheworkforwhichthispermitisissued - - P.L Sec. 3097, Civ. C.). SIDE Toronto'"Dominion Bank PL _ ... Lender's Name- 144 Sansome St. Sui to .700 LDMA Ref.# LendeisAddressSan s P.C..'Fe SS---3-xv Permit Fee - •s- --.... I certify that I have read this application and state that.the "& Fianciscu 4/`s c Issuance Fee -/D • IOMA P/C # above information is correct. t agree to comply with all County Invesligotion Fee ' S ordinances and Slate lows relating to uiWing construction, ' Tolot Fee- - h D_.: .LDMA Perm.-# ._- and her authorize epre ntati s f this County to enter - - - - - u upo Ih abo •me farted roe y r Inspecti n pu pose u_. .. _ ... -. .. - - SEE REVERSE FOR EXPLANATORY LANGUAGE Dote O ice p' " v = p•'.r p. L" .- C "^tzS•F ZT a a .(, ^. N r-- r-- N a t S- p p~ F_'t, a a' b : « F• h a s N • OCD tiytiC•N7'b e• C .^ .f9 721 a"'.A .• N< w`+r N •'N.L v _'T R SoCocr ti' -• ce C. i O7 7 O Zz A p •.• fC O to y . in S O y ` . .Y N C? r S C M.a3 m C a.a N w Q rCCD a it r c a Q-7 N .`b c -o n• o.N CFb CMS-`4•O z ten'• m moo' nfip 0Q Npcm CD sNapM^ c M 4 v_f ZSC` 0. n_ '' O °- _ y 5 M c A ^. o T. N0 O c 1 ti F i. in i N w V ?a 0.p C s a Z e cGn:. o ` e Ip C p N 1 rJ l0 1 M A ' d S ti `C N N •` N C' N