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HomeMy WebLinkAbout7177AU ¢ M WORKERS' COMPENSATION DECLARATION hereby gffirm that I have a certificate of consent to self insure, or a certificate of Workers' Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab. C. ) Policy No3B813-37�8mpanylndustrial Indemn Certified copy is hereby furnished. Rkr]_ Certified copy is filed with the county building inspec- tion department. Date A15-R1-Applicant Arni Pm & Sans CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number 329595 Lic. Class B-1 Contractor Arciero & Somste 4-15-81 I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer acting in my professional capacity (Section 7051, Business and Professions Code). Lic. or Reg. No. ® Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C. ). Lender's NomeHOmestead Savings & Loan Lender's Addressl777 Mu rehison,Burlingame I certify that I have read this application and state that the CA above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above -mentioned property for inspection purposes. APPLICATION FOR BUILDING PERMI1 BUILDING ADDRESS FOR APPLICANT TO FILL IN BUILDING ADDRESS LOCALITY NEAREST CITY Diamond Bar ZIP CROSS ST. NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACT 3 7 0 2 6 BLOCK I LOT NO. USE ZONE MAP NO. TEL. SPECIAL OWNER Atciero & Sons No598-1821 CONDITIONS DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS20001 E. Walnut Drive I CONST. ZONE CITY Wa 1 nut., CA ZIP 91789 STATISTICAL CLASSIFICATION APT. CONDO. CLASS NO. DWELL. UNITS INEENEEM SEWER MAP BK. PG, VALIDATION ARCHITECT OR TEL. ENGINEER R. J. Marvi ck No.9 7 - 7 6 6 5 ADDRESS CONTRACTORArciero & Sons No.598-1821 2 0 0 01 Walnut Dr. No2 9 5 9 5 ADDRESS .3 VALUATION $ 104,300.00 7 CITY Walnut, CA 91789 cASS B-1 SQ. FT. NO. OF NO. OF " CHECK ONE SIZE STORIES FAMILIES , DESCRIPTION OF WORK NEW ® $ f 1 It 0 0, 0 FINAL condominiums ADD ❑ ALTER ® ® REPAIR DATE FINAL By 0 LI, 3 `' c USE OF EXISTING BLDG. DEMOL ❑ APPLICANT TEL. (PRINT)Sons No598-1821 ADDRESS 20001 E. Walnut Dr Walnut PRESENT BUILDING ADDRESS LOCALITY 1 MOVING TEL, CONTRACTOR NO. ADDRESS , / ,). ® d j REQUIRED SET BACK YARD HWY TOTAL SETBACK FROM PROP. LINE EXIST. WIDTH FRONT P.L. SIDE P.L. P.C. Fee $%y! /f Permit Fee Issuance.Fee Investigation Fee - Total Fee Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE ©s