HomeMy WebLinkAbout1030 N GOLDEN SPRINGS DR (6) ��..
' WORKERS'COMPENSATION DECLARATION . . . . ��
��;�;e6o,a'�e°;;,;�a;e'ofwo.ke:ef�omPe�S�o�°��=�;o��eso'; - APPLICATION FOR BUILDING PERMIT
o certified co �hereof(Sec.3800,106.C.) COUNTY OF LOS ANGELES BUILDING ANP SAFETY
r�oRcy�S—��1-391 ComPa�y �'9�ridut '
� Certified coPY is here6y furnished. FOR APPLICANT TO FILL IN ADORE55 1a30.N. Golderi S rin Drive
� Certified copy is filed wirh the coumy build�ng inspe[- ' gURDING
rion departmenr. , p A�DRE55 1030 N. Golden rin s�Urive iocnury Di nd B
n i�com aTr nd B zic 91765 caossSsr. Sunset GYossin
Dote . ��Z7�82 PP ��+ ������
� � CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. ' ASSESSOR
� � ' COMPENSATION INSURANCE ' � SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(Th�s sea�on need noi be completed i(�he permit is for one ZONE rnnP � p
hundred dollars(5100)or less.) 7enCi 31274 B�OCK L��i[3(', 4 �� NO. � �_ ��1 �
� TEl SPECIAL y
pWNER � ��[� �� n,�99-6864 d CONDITIONS
I cenify that in the performonce of the work for which ihis . �
permil is issued,I shall no�employ any person in any manner �ISiRICT GROUP TYPE FIRE PROCESSEo BY
ADDRE55 629 Cavina Blvd.
� so ns to become subjeU to the Warkers'Compensation Laws. ' b �1 CONSi.,� zD a,
;r_ �.
'Dafe � ' �qppiicon�'� � CITY ZIP 1�]�]3 57q�15TICAL C1A551FICATION APT. CONDO. V
��NOTICE TO APPLICANT: If, affer moking this Certificote of - /+RCHITEC70R � TEL +t'1 �
Ezempfion, you sho�ld become subject to ihe Workers' ENGiNEER r � 2 ^'�7� CIASS NO.Q�DWELL.UN�TS � N
Compensalion provisions of�he Labor Code,y0u mU51 fOfl{I- qDDRE$$ 4766 Park.Gx'anada� W���$ SEWER MAP Z
with comply with such provisions or Ihis permif shall be TEI.
deemed revoked. � . . . � CONiRnCTOR THE ANI�1 GROUp No599-6864 BK. PG, VALIDATION
. LICENSED CONTRACTORS DECLARATtON �� LiC..
I hereby affirm thal�om licensed under provislons of Chop�er 9 . ADDRE55 629 Covina Blvd. NO. 371J8� VALUATION .
(commencing with Section 7000)of Division 3 of the Business and liC.
Profess�ons Code,ond my license is in full force and effect. Ciry $31] D1TI13S � � CtaSS B s365,000.0� - � '� � -�
3�I�SQ B S�EFT. NO.OF NO.OF CHECK ' ' :
license Number Lic.Class a STORiES 2 FAM4iE5 7 ONE �2 3 9�a
�,' �T (�OTIP, 4 Z�I HZ DESCRIP110N OF WORK N� ❑Y' E ' '
�Conlractor Date - ADD �� . #;• • • •2.1
� I om eKempl from Ihe licensing requiremenis as I am�a _ n
licensed archilect or a registered professionol engineer .. .. _ ALTER � FINAL � •7� 7�3 6
. octing in my professianal capacity (Section 7051, REPniR �ATE ���'/�-3 '
Business and Professions Code). u5E OF r � FINAL •�'71 7 3 6 c�i �
E%ISTING BLDG. DEMOI �
Lic.or Reg.No. Do�e APPI�CANT iei. 8Y 0��3�8 2
� �� OWNER-BUILDER DECLARATION � - IPRiNT) ' N0599—OHF)4
I hereby offirm that I am ezempt from the CoNroUor's license qDDaE55 629 Covina Blvrl, San Dimas, '� � �2 J 9•a A
Law for the following reason(Settion 7031.5, Business ond �
Professions Cade�: . � � PREoEN
#• • •'•�•;�
BUILDING
� I, as owner of the property, or my�employees wHh � qoDaE55 - . �'1.28950
wages as their sole cem�ensa+ion,will do tha wcrk and �. � '
the structure is not intended or ofiered forsale(Section �a"��T� � � - � - � •.1.2 8 9.5 0 v
70Ed,9usiness and Professions Code). MOVING � TEt. ' . �
' � I,as owner o(�he properly,am eMclusively contracfing � �ONTRACTOR ' NO. - � _ � O�O�J s'$2
with licensed conlractots to co�sirucf ihe project(Set- ADDRE55 � - �� � ' � � �
�ion 7044,Business and Pro(essions Code). � - � � �
REQUIRED TOTAL SEIBACK FROM EXIST. • '
' CONSTRUCTION LENDING AGENCY SET BACK YAR� HWY ,pgOP.LWE WiDTH ��• - • . . • • . . � -'
� I hereby affirm thot there is a construction lending agency for FRONi �
the performance of the work for which rhis permii is issued v.i. _,,. . , - ,
(Sec.3097.Civ.C.J. . . .SioE - - - � , _ - . . ., -
Conti.nent�il Illinois ' '`.
Lender's Name� , _ . // .7 /� ' ' � ' . ' ' � . ,
231 S Ia Salle� al7;CdgOr z T101S p,C.Fee 5 . /� /.� Permi�Fee Z/� �
lendei s Address ' p ��- � '-' � � ' �
I ceniiy tha�I hove read ihis oppi�carion and state Ihol the Issuance Fee d•S�
. a6ove informo�ion is correct.I agree 10 comply with oll County �nvesrigae�on Fee ' �
ordinances and Slale laws reloting�o boilding construdion, . Toial Fee f���•sd
1 ond hereby o horize represeniotives of ihis Coun�y to enter
�upodfhe e-mentioned roperty for inspection purposes. . � �
`�rt.. � 4��L�I�HZ SFE REVERSE FOR E%PLANATORY LANGUACE
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