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WORKERS' COMPENSATION
RS' ION DECLARATION
4
I hereby affirm I hove C ertificate of consent to. self
insure, or certificate of Workers' Compensation Insurance,
� �
I CATIFCIV F C� R
i
. B U IlD l N G PERMIT
or a certified copy thereof (Sec. 3800 Lab. C.)
QWC005 279—�D004' Nationwide
30/A COUNTY OF LOS ANGELES
BUILDING.AND SAFETY
I
Ize. , o ompany
Certified copy is, hereby furnished.FOR
APPLICANT TO FILL IN
BUILDING
ADDRESS 24317 E. Sylvan Glen Road
Certified `co is ft ed with"the count building in pec -
copy � Y 9 � P
'
BUILDING
24317 E. Sylvan Glen Road
tion
tion department!
ADDREss
5/19/86 THS ANDEN
Date Applicant ,GRdUP.
CITY Diamond Bar ZIP 91765
LOCALITY Diamond Bar
CERTIFICATE OF EXEMPTION FROM WORKERS'.' `'':
NO: OF BLDGS. - -
NEAREST !s_•
_,..
COMPENSATION INSURANCE ''
SIZE OF LOT NOW ON LOT
CROSS ST. High Knob & Golden S
rings
(This section need not: be` completed if the permit is for`ane
35754 61
MAP BOOK
hundred. dollars ($100) or, le{s) . ;
TRACT BLOCK LOT NO.
PAGE
PA RCEL
-
o
I certify that tri the performance of the work fpr which ; this
OWNER N L. _ _ .. _ _
-
USE�ON _P
NO.
�t v
permit is issued, 1 shall not employ any person in any manner
P 0..__ B0X _3329
ADDRESS ' -- -
l�{ SPECIAL
(J� CONDITIONS
-
I 0
so as to become, subject to the Workers` Compensation Laws.
!
:, �.s .:, , ; O
CITY_.._. . Covina ._ ZIP __ 91.722
to Applicant
JTICE TO APPLICANT:' If, aftenmaking this Certificate of
ARCHITECT OR TEL.
ENGINEER Dae an AIA. No. 445- 0 3
DISTRICT GROUP TYPE. FIRE
PROCESSED BY
`'-
_
Exemption, you should become subject to the Workers'
Compensation of the Labor Code, must forth-
314 N. First, Arcadia
coNsr z
) -1 n�3
Z
„ I ,
j
provisions you
ADDRESS
1
with comply,:with such provisions or,'. this.permit shall be
- TEL
I
deemed revo,ked,. ,,
CONTRACTOR THE ANDEN GROUP NO.
STATISTICAL CLASSIFICATION
_.
APT. CONDO:'
r Z
LICENSED CONTRACTORS DECLARATION -..
... -_ -. _ _ ._ LIC . _ -..
CLASS NO. DWELL'; UNITS
}
thereby affirm that I am licensed under provisions of Chapter 9
ADDRESS NO.
(commencing with Section 7000) of Division 3 of the Business and
LIC.
SEW MAP
ER
fessions and my license! s In full force and effect
Li
.. B
CITY CLASS
- -
BK.
VAS IM
gA1C1 A
ense Numbere'
3 71S80 Ltc, Class ' Bim`
SQ. FT. NO. OF __ _ _ NO. OF CHECK
SIZE 1]86 STORIES FAMILIES 1 ONE
PG.
4
-
Contractor THE ANDEN GROUP Date '5 /19/86`.
DESCRIPTION OF WORK EW
VALUATION
65 O52
t ® 268.,&5 j
am exempt under Sec.
-Garage - 447 SF [3s
r
ALTER
e 26 8-&55
B.&P. C, for this reasonREPAIR
0
s __. .._
j
0605-86
Date:
USE OF
EXISTING BLDG. DEMOL
Signature'
g
APPLICANT - TEL. i
PRINT THE ANDEN GROUP NO.
FINAL
OWNER -BUILDER DECLARATION
DATE .: L.,�•-g.�
I hereby affirm. that I am exempt:from-the Contractor's License
As above i
law for the following reason (Section 7031.5, Business and
ADDRESS
FINAL'
�fessions Code): __ . _
PRESENT ---L
.By
`A
q the employees
LJ 1, as owner
BUILDING
i
':®
wages as their sole cf ompensation, will do and
.. _
''
the structure is not intended or offered for sale (Sectionf
LOCALITY
7044, Business and Professions Code). _
MOVING _ __, TEL.
O
ElI, as owner of the property, am exclusively contracting
CONTRACTOR NO.
with licensed contractors to construct the project (Sec-
- - - -
-_.-__ j_-
®_ .'5.9 0 E}
tion 7044, Business and Professions Code).
ADDRESS
a i
CONSTRUCTION LENDING AGENCY
REQUIRED. TOTAL SETBACKFROM'EXIST.
SET BACK YARD HWY PROP. LINE WIDTH
I
- i
0 p' Q `J &6
I hereby affirm that there is a construction lending agency for
FRONT
the performance of the work for which this permit is issued
PrL: '
- -- - - j. ----•-
- --• - - ------
(Sec. 3097, Civ. C.).
SIDE
I
_ Continental Illinois
Lender's Name
Lender's Address 231 S. LaSalle-,- Chicago, IL
P.C. fee $ - Permit Fee 37 9 .50
LDMA Ref. #
-
certify. that I have read this application and state that th�O693
_ Issuance Fee -l' 50._._LDMA
P/C
above information is correct. I agree to comply with all County
Investigation Fee
ordinancesand to laws relating to building construction,
TotalFee -
#ee
-tDNA Perm:
--- _
and hereby a o ze representatives of this County to enter
upon the a v e Toned property for inspection purposes.
;.
_ —
-T
__ -LDIKA $10 9 $55-
_
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signoture of Applicant or Agent or Date
House Number -
Correct & Posted
Final—
Enter on Front
INSPECTOR'S NOTES OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason. (Sec, 7031:5)
u.
PLANS TO APPLICANT
To:
Returned
Approved '
Business and Professions Code: Any city or county which
requi>es a permit to conS"ct, alter, improve, demolish,
orrepat .any -structure; to.its issuance .also requires
No. Date
No. Date
the applicant for such>permit to file a signed statement
-' -------- `-' that he is licensed fiusua7ft,% the firovirions of the Con-
u. � _ _ F ,:.. ; ... = ` tractor's License Law (Chapter 9) (commencing with Sec-
son o Divisi"J o the Business and Professions
Cod¢J or �htit'he isex¢ntpt. therefrom and the basis for_tbe
alleged •exemption. Any violation of Section 7031.5 by
- - �- - r any applicant forapermttsubjects the applicant to a civil
p
:,equired
Dote Received
Approvals
or Approved
penalty of. not :more than ftve. hundred dollars ($500).):
Yes
No
❑ I, as owner of the pro`p'erty, or my employees with
a, wages as their sole compensation, will do the work, and
Water Certificate
the structure is not intended or offered for sale'(Sec. 7044)
Business, pnd Professions Code: The Contractor's License
Heglth Department
Law does not apply to an owner of property who builds
or improves ereon, and whdoes suchFire Z�
that
_Department
through hist own employees, provided such
rovements are not intended 'or offered If
p nor sale _ f ,
Grading `'
however, the building, or improvement is sold within one
year of'.contpletion, tthe='owner-builder will have the
Geological
burden of proving that he did not build or improve for
the purpose of sale).
I
Redestrian Protection
(Fence) (Canopy)
I, as owner of the property, am exclusively contra`-
Elwc,
ting with licensed contractors to construct the project (Sec.
7044) Business and Professions Code: The Contractor's
Special Inspection`
(Cont.) (Masonry) (Welding)
License Law does not apply to an ow>}er of property who
builds or improves thereon, and wlio`contracts for such
projects with a contractors) licensed pursuant to the
Lot .Drainage
- • Contractor's License Law). •-f
'' "• ❑ I am exempt under Sec. , B. &P. C, for this
reason
_ .
Date Owner
INSPECTOR'S NOTES
parking
Approvals
Date
Inspectors Signature.
Location—
s'
(Setback & Yards)
Foundations
Slab
Frame
Energy Insulation
Lath/Drywall—
Interior
Lath—Exterior
t
House Number -
Correct & Posted
Final—
Enter on Front