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HomeMy WebLinkAbout1030 N GOLDEN SPRINGS DR (11) ��.. ' 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 Slgnmure ol Applimm o gen Do�e - �s ;'^ fl 2 0 0 � „ v' o' in o ' 'o y n rn :,,� G1 G� _n 2 � z -� � Qo m o o• �; m_n --. .> , , � _ ov � o � :o o . o 0 m'o �� � � m � o-' '� o n � a ��; p, �.n � m o °a m ° 1 O � ..^.� rn � O �C � �.O � : m. p� � O � � � 7� m T ' � �y Z x �..� � 1 � n-.� t� ] - : � '"'_ �o ^ n � 0 n , -*+ � �c o f � c• ° ce I � - �� r� �� o ° 0 1° 2. ° 0 3 0' � ° o - '�^ . -c.•. � . - ,o� o;� � v - 3 Q � � � � m � - `_ o 0 on o0 0 " r; a i o �_ . Q-, v� � � • �. ty � � 3 0 � , �C - 7 '�, u�_ ) v7 vn ? fr' p O . 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