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HomeMy WebLinkAbout0958A 0959A (5)WORKERS' COMPENSATION DECLARATION •••;-. , <:y .,„•• --” - "' -' I hereby affirm that I have r certificate, Comte ns tion Intra = elf ---- - - APPLICATION -'FOR BUILDING PERMIT-- - z9 insure, or o certificate of Workers' Compensation Insurance, PERMIT - or a certified copy thereof (Sec. 3600, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETYPolicyNo61WETX7991arnanyHartfordGroup 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- lion department: ADDRESS 24445 East Thunder Tr ' Datej/S2 Applicant -- CITY Diamond Bar ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' -- -- "' -' -'- NO. OF BLDGS. - - -- - NEAREST._._.. COMPENSATION INSURANCE SIZE OF LOT NOW ON LOTCROSS 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- _. 5EZIcertifythatintheperformanceoftheworkforwhichthis1NO.- - _ U 17 J AP NO permit is issued, I shall not employ any person in any manner - 3161. Al rWa AVe . SU i to N . ?/-/- SPECIAL - ! .- - -. CLastobecomesubjecttotheWorkers' Compensation Laws. ADDRESS •y- s - - i&,, 0 CONDITIONS O CITY Costa ZIP.. U Dave - . , -Applicant : , . ;. -, . . , . _._ - - - - .. OARCHITECTORTEL. LICE TO APPLICANT: If, after making this Certificate of p15TRICT _ GROUP TYPE _ FIRE PROCESSED BY - FENGINEERNo. 752-1864 lJ jn ensat you should become subject- , y the Workers' -- - OR ZONE l.ompensation provisions of the labor Code, you must forth- ( 3 wADDRESS3990WesterlyPl. Suite awithcomplywithsuchprovisionsorthispermitshallbe -- -- - deemed revoked. TEL STATISTICAL CLASSI KATION APT. CONDO. N CONTRACTOR NO. 850-1 1, ? LICENSED CONTRACTORS DECLARATION - . - - - _ .. - - LIC __. _"_._ ._ ____.. CLASS NO. DWELL UNITSherebyaffirmthatIamlicensedunderprovisionsofChapter9ADDRESSNO. commencing with Section 7000) of Division 3 of the Business and - . LIC.- SEWER MAP Professions Code, and my license is in full force and effect. Cltt CLASS B --- - BIC ; -- - -- - VALIDATION 409610 _ 50. FT._ NO. OF _ _ _ N0. OF: _ _ _ _CHECK License Number Lit. Class , B SIZE STORIES FAMILIES ONE G Lira 8 A VALUATION Contractor Brama1 ea Calif Date DESCRIPTIO A'C ORK PAN 3 - NEW © ; - •' ' fid/ Ir.,•°:;1 . Sin le Famil sidence ADD ' I em exempt under Sec. ALTER I ° 2 0.11 1 B.BP.C. for this reason REPAIR _ - - - - - '" j , ;I, 1 Dat - - USE OF BLDG. None DEMOLEXISTIN0 20-8bSignatureAPPLICANT George Vedell no. _j FINALOWER -BUILD R DECLARATION _ .. _ -DATE 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 - - - BUILDING _ f, as owner of the property, or my employees with ADDRESS J Awagesastheirsolecompensation, will do the work and 9 the structure is not intended or offered for sole (Section LOCALITY 7044, Business and Professions Cade). -' ' - - - MOVING - - - - - - dsr> r %: ° . I, as owner of the property, am exclusively contracting CONTRACTOR nwithlicensedContractorstoconstructtheproject (Sec- ADDRESS `• -( `'y /I O" 0 0tion7044, Business and Professions Code). REQUIRED TOTAL SETBT. _ _ _ CONSTRUCTION LENDING AGENCY - SET BACK - YARD HWY PROP.H - - -- (L y' C. hereby affirm that there is a construction lending agency for FRONT u i [ C - 8theperformanceoftheworkforwhichthispermitisissued - - P.L.-- _ ___ _. Sec. 3097, Civ. C.). SIDE Toronto-Dominion Bank P'`' _ Lender's Name - - 144 Sansome St. Su i to .700 7 nn CDMA Ref. It Lenders Address s P.C..'Fe SS----Xv Permit Fee' - I certify that I have read this application and state that.the n"'rJQ /`s r Issuance FeeIOMA P/C 0 above information is correct. t agree to comply with all County mvesugotion Fee ' S ordinances and State lows relating to uildi ng construction, ' Tocol Fee- - h D_.: .CDMA Perm. -M ._- and her authorize epre ntati s f this County to enter - - - - - u upo Ih abo •me toned roe y r Inspecll n pu pose u _. ie SEE REVERSE FOR EXPLANATORY LANGUAGE at 1 or ge - - - - 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 co • QCD 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 •.• (C O to y . in ^ S O y ` . .Y N C? i o_• r S c^-"e'oce C a't' aM.a3m C a.aNw Qr... CCD a it s o a Q-7 N .`b c -o n• o.N CFb CMS-`4•O z ten'• m moo' nfip ma Np°m CD o sNapM^ a M 4 v_f C` 0. n_ '' O °- _ y 5 M c A ^. o T. 07 C A O N O o 1 ti F i. in i Ti- N s a Z e p o ` e Ip C p N 1 rJ l0 1 M A ' d S ti `C N N •` N C' N