HomeMy WebLinkAbout0888A 0889A (4) � t �NQRKERS'COMPENSATION DECLARATION �
I hereby�ffirm fha�� have a�ar„f,�a,e of�o�sen„a se�f qpp��CATiON FOit BUILDING PERMIT
insure,or a certlficate of Workers'Compenstlon Insuwnce,or
a certified copy rhereof(Sec 3800,1a6.C.) [OUNTY OF LOS ANGELES BUILDING AND$AFETY
Policy No. Compony
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN gu��o�N�
aooaess •i �
❑ Certified copy is filed with the munty building inspec 6WLDING
��on a�Par�m�n� Aookr:ss 2544 Wa on Train Lane �ocn��rY Di.amond Bar
N[AREST
�ato Appl�conr cirv Diamond Bar ziP 91765 ceosSsr Stee 1.2 Chase
�, CERTIFICATE OF EXEMPTION FROiYI WORKERS' NO.OF BLDGS ASSESSOR
� COMPENSATION INSURANCE SIZE OF LOT NOW ON LOi _ MAP BOON PAGE PARCEL
" This setlion need no�be com leted if ihe ermit is for ane O p �USE��L-OJJE MAP
'� hundred dpllars($100)or less.) p TkACT 3Q570 BLOIX LU?NU_ IQO �f'�'/ NO /���'�`='�' � �
�, T[L .����� SPECIAI a
''� I certlfy ihat li ihe performance of ihe work for which this �WNFR pll�S Piermarini N0.598-26�6 CONDI7iON5 �
��.. permit is iss'ued,I shnll nof emplo rson in any monner DISTRICT GRDUP TYPC FIRE PROCESSED BY (�y
� so as to 6emme subjecl lo Ihe orke ' a+�ensation Lnws.
AooKEss 1633 Derrin er Lane �ONST ZON[ u
t R',n--'
� %���,��r uT� Diamond Bar CA z�P 91765 10 R3 -c« �
�, Date— Applico t� �- --- 57ATIST�C.At(:LASSIFICA�ION AP�. CON�O, �j
�� NOTICE TO P.PPLICAM: If, afl,r making this Cerlifimte o( ARCNiitCTOR F c �
'��, Exemption, you s hou l d hemme su bjetl t� t he Wor kers' ENGINEER �� ^ 1 ^ V 1 CIASS NO r� �WEIL UNITS_ �
'�. Compensation provisions of the Lobor Codc,you must forth- nnuetSS �ran�e t CO lII8 SEWEH MAP �
,, with mmply with such provisions or Ihis permit shall be TFL
�i deemed re:voked. CONTRACiOk �01115 Piermarit��. BK PG, VALIDATION
��, LKENSEU CONTRACTORS DECLARATION �i�_.
! I hereby afflrm that I nm Ilcensed under provisions of Choptar 9 ADDRE55 ,,SB,jIIe yq��� ri��ry�
,.R.>.
'� (commenuny wilh Sechon 7W0)of Division 3 0l Ihe Busmess and pC 7/
Professions Code,and my lir�r�se�s m full force and effecf C;iv CLA55 `� e�'��
158432 17�•1 SILtF.,.CJ,� 5T012E$ AMIIIFS CONFK
I License Number Lic Class
I Controcto�L•ou;s� Piermar���. UESCRIPi�ON OF WORK NFW � S
� I arn exempt from ihe Ilcensinq requirements as I am c s ruetion-/�e� , ADD � �Q�i�,��A
licenseti arci�itecr or u registered professionol engineer � A!TFR � FINAL
a�r��9 �� mY professioncil �a�a���Y (Sectwn �os, / G L 3 . �E�,AiR � OATF �• ° • °,Z�
j Business and Professions Code). USE OF
� EXISfING BLDG. DEMC>L � FINAL � s �G 3,G 0
158432 oa,e A�P��cANT � e'' �
Lic.or Reg.No. q n �
! OWNER-BUILDER DECLARATION �PRiNi OU=TS Piermarini �A8-2666 -'-3�2 G��
� I hereby affirm that I om exempt from!he Contrador's License �2 Gt 5,��1
� Law for the following reason (Secllon 7031.5, 8uslness and ADDRESS ��
� Professions Code): PRESENi
6UIL�ING �
I, as owner nf the property, or my employees wnh ADURESS �� j
I � wages as�heir sole componsa�ion,will do the work and � �,z(�b'�E,,C��
� the str�cture is not intended or offered for sale(Section ���A�'�Y �
! 7044,Business and Professions Code). 7d�OVWG TEL. .,(�- �j� � ,,;; ,
I � I,os awner of ihe properly,am exclusively contracling CONiRACTOR NO rw� ��� �-
�J
with licensed centractors to mnstr�ct rhe project iSec- �� -- � m u �,�j(�
Ition 7044,Business and Professions Code). �DDRF.55 .
I NE(]UIRED TOTAL SFTBACK FROPn EXIST. � ' 2
CONSTRUCfION LENDING AGENCY SFT B�CK Y�RD HWV pKUp �iNE WIDTH /"TC ��� � e � � '`���
I hereby affirm thar there is a construction Iending aqency for ;gnNi ' J
tho performancc of ihe work(or whl<h ihls permrt is issued P� �� �2. .�—8
I (Sec 3097,Lrv.C.�. 9Dh � �
PL `
� Lender's Nome NOIIE �� �� \ C� `���
� ;� — � P.C.fee 5 Nerinit Fee ��J.,,`�� �J
Lender's Address_____._ (1,
� „', I cerfify thnl I have read this application and stafe that ihe Isw cc Fee � ��\,y `
� Q above Informotlon is correcl.I agree to mmply with all Counry irnest�qaiion Fee � � �
ordinanceg � � laws relating to building consiruction, inml fee �'�� ��..>� ��
�� a d h +'eb ihanze presenta�ivr,s of ihis County to enter ��
D upar 1 ove-men ned propxrry for inspection purposes.
I �._.._.
I �f ����"��°:�--<"�—C.�—'�a..,,.s--s SEE REVERSE FOR EXPLAN,4TORY LANGUAGE - �
�� Siqnrnuro 04 Apolrcnn.cr Ayen; Doie �s
_ ' _ ---_;_---i � i "".' �i��� � �
� � ,� '�� � Q t � �
yyy ~� T� �'J C7 Q � j p� �r A i N �3
4 fl-
� r� C (9 � w �� 3 N s � Cl �
r^ "^ �� 1 O N n X U � n' J� o
� � �� ! . � �. • '� ¢' t° �O O ro �
.� _"."�" m-�C�x S 9 m ° �v 1 a Q c i Sg W � ° fl ^ I � � �� '�
� N R��C I 3 O� � 8 � F� � �Q �u'+ 4� . :3 ; � p � n l � O
p 'i �� X m�1 w � �� � � fl-� .'o� o � � ` � 1 M p i W
o � � �
-�n Q°`' � ° 9 c N o a ' o 't � , � y. � "' i
i � �R� O i � A, � '°` �.� J� i ! �
1 �� � � � � � � � r
I � ` �
I � 3 �
� ! ._—� 2°� -t
1
' i � � � - � � � � M 1� ` 0 4 �
� � � ,
, ; _ --� -�� � a� � �
� � �— - — '� 9 � + o � �� � ro °" �
t
� --- � � --____.'----� `_`�`� �- �
,- � � � _ : � � �
� , � ; ,, �
op
N �
1 � O I � �� �
� I � ., � ':� �S � � 9
� I ' � � l � � , if E � � � �
� � I '� #i �.� �.
' �
�j ` '' � � � ��
` i L_ - l , `
�--- I i
� I i �
i
� � � Z
� � N
f q
m
�
� � � �
I ; � �
�
:� Q
, � . �
� � � ; �
N
; � �
, � � � �
` �� �
� I ' � ,
I , 1 �
�
1 ' ° � qn�
.��. n cY n::.-i s�s�w,a H m s
t c. O l�1 s� � O � A a a ^t
� ) K C]"Z S'� t:� "w1 '� (D Q - +� L 'c A'r f' p p �-g N tp
�`tl' M r,�-� p � � O o .�° V j�n !_ ��� �.�!-°4 m"�ey� � y cD CT
� T O p n A� l `t 3 cn C O C '
' Q O � u. 'w A �.I� R. C �o a R} Q N c �C'7 , C�"y .Y y� � r� ..�+
I � o ❑ � � �� �f. �� �,� � a� N � � UQ `,p� �.,ann��p � � ��
S � v`~, O �`� S Q O"�"p w h y � �R,m fJ C ���C 'r�N H`"`a' + � D � �
� o ° p � •n � �,'o. � ^'r w � s `'^� m C7 e� m ° *R ^•0 7��'
x t+S� a�.H � � `�c,o�A � ��000c'-�o � A � A'»•a.v�� `n�"' oN s° C
• ' � �� � � � �ro �� 0 0.� � ° �;, � � °, "m �m ° � e S a o y � " t�.
� j � xov � a.00 ...�ax » '� � �coo T ;S.`� s � � (��'r'sy o° C
" ^ K � y �i �a w a � � 3 M ��b.Wsa m r .' 3 er
� ; � cJ '`S w '� 3- p �'U � � rn O..Ty � �.. N O A .`4 ^t �t �O
� 3 �,^�A � oao m �'� � o0.� nQm� �ti o »�•,'crK� � � � X �
� an � A :, m,��,�^--a � .A:z � o o N o c'� %s 1° o �' _ �' � co C�
� n �, �.o ���.�-°o �e'� m� a� ".��. o °� ��'.ti,a `s.ti �•a�ca.3v �
� I _I � �SS � � O cD �+,�1.� O R. a1.`.�R �..i-"°'i,j K �°` +n' .Y O ����y y� t0 •r.r
� C � a J p a�Z."� O � .u'..o� [J i.'Y'i `. �
I � � n a.x n� � �' �� � � ��`" a�. ,-�, �`"Q � � C a a =`z ° 3 'Y
� �' �� �� � s...�°,�i.� � ^\ =3 a'� ��R.� � �^ "•n"�`^`e � ? 5«
` � a.° += �' n x ^,� :� �;'� a,v� x � Om ?,°a.`�" 3.� � �G' `° e " in`° n
� .� *j �^�eym -� aQ 3 »oc� � �aro °
` ` `°' £ "� � ;,,,u s c '� a�u�� Q m'�a � �' � �'��o ° y o W� `•' ° �
;� �,,� m co �'. °% �. n� rn o h.� �'-" ,� ;z �
; � � m ti � ? �-o � �• <..� � y 3's n`ccno o� `�=o w�.,�:'m o.c � � p° - .
� y � :b � �.'� '^,qS .A^' N � �� � �n F N �„yy.p �..O N u � � �.u G:p
n^n y- N n `Z'p S,n aT n V' .? U K p(n p o �4 �, n ��
n � � � � = o � � O � ��,� A 3 �. `�:��y n � � y � �" v
� ° �, x � a m o o"��a -°� ���°"�" .__.�
`�+ n � -q m �
I S m� "'
1 � I • N . _.�.y_�`.�
� ,_,_._.�-�"'���_...`��_
I ,,,_.._�..-,.--�-^e"'"""'_"'_..___.- __�_----.--'___--
..�.-.-----�_'",...-