HomeMy WebLinkAbout1568A 1569A (9)WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -
insure, or a certificate of Workers' Compensation Insurance,
ar a certified copy thereof (Sec. 3800, Lab. C.)
PorcyN0.73Wc005-2�76 NATIONWIDE
Certified copy is hereby furnished. -
Certified copy is filed with the county building Inspec-
tion department.
Date 6-30-87 Applicant THE ANDEN GROUP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (SIDO) 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
r"'aTICE TO APPl1CANT: If, after making this Certificate of
sorption, you should become subject to the Workers'
Lompensation provisions of the Lobar Cade,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 Number510560- tie class B
ControctorTHE ANDEN GROUP Date 6-30-87
I am exempt under Sec.
BAP,C. for this reason
Signature -
OWNER -BUILDER DECLARATION
I hereby offirm 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). -
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
Iion 7044, Business and Professions Cade).
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 Name CITIBANK
tender's Address 444 S. FLOWER, LA 90071
certify that I have read this application and state that the
above information Is correct. I agree to pJ
comply with all County
q ordinances o ate laws relating to building construction,
Q and hereb f u f prize representatives of This County to enter
S upon It �- ned property for inspect' n urposes.
Signature oI Applicant or Agent - Dote -
L•ut 25 Pc��ce�l� slot oaSob5
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS 24020 E. Goldrush Drive
nooaEss 24020 E. Goldrush Drive
CITY DIAMOND BAR
zIP91765
Loc°.Llry DIAMOND BAR
SIZE OF LOT
NO. OF BLDGS.
NOW ON LOT
NEAREST
CROSS STDIAMOND BAR BLVD . + GOLDEN SPRINGS
TASSESSOR
RACT 43435 BLOCK
LOT NO. 25
MAP BOOK PAGE
PARCEL
owNERTHE ANDEN GROUP TEL*
—9541
U ZONESPECI
—�
a v�J
NO.
ADDRESS P.O. BOX 3329
CONDITIONS
CITY COVINA
zip 91722
ARCHITECT OR
ENGINEER DAVE SZANY
TEL.
AIA NO.445-4073
DISTRICT
)J
GROUP
�-,3
TYPE
m r.
FIRE
PROCESSED BY
ADDRESS 1
f
- TEL. -
CONTRACTORTHE ANDEN GROUP NO.
STATISTICAL CLAS51-FIXATION
py
CLASS NO. DWELL. UNITS
APT,[CONDO,
ADDRESSAS ABOVE
N0.510560
SEWER MAP
pG.
Ap�
VALIDATION
LIC.
CITY - - CLASSBK.
s°EFT' 1658 S10ROE5 2 F MI�ES 1
CONEK
DESCRIPTION OF WORK I
I
NEW a
STOUU
llUuAllllJ , 0
'
:-: 1 5 68 A
ADD
GARAGE 456 SF
$
FINAL
DATE J/—� i3
}} • • a • 21
1• 31 6 8 4
• + 1 6 8
0 9. 1 1 — 8 7
REPAIR
ALTER
USE OF
EXISTING BLDG.
DE/hOl
APPLICANT TEL. -
PRINT THE ANDEN GROUP NO.
ADDRESS AS ABOVE
gNALWO
„"�
y —PRESENT
.
BUILDING
ADDRESS
1 5 6 9 A
$i s • • a • 1
- i
LOCALITY
MOVING - ^` TEL. '-
CONTRACTOR
NO.
ADDRESS
T �) -
-' r��'.
r_L,;, ;:'�)�
•° 5 0 7, 0 0 5
o9,11--87
REQUIRED
SET BACK
YARD
HWV
TOTAL SETBA K
PROP. LINE
WIDTH
FRONT
SIDE
P.L.
M R
LDMA ef.
'
P.C. Fee S 316.84
Permit F•e .496.50
!
10.50
1,,uence Fee
Lou✓ Pic Is
LDMA Perm. M
Investigation Fee
Totai Fee 507.00
IDMA $75 $35
SEE REVERSE FOR EXPLANATORY LANGUAGE
O
U
!r
O
w
s
r1U
Z
PLANS TO APPLICANT
INSPECTOR'S NOTES
Approved
No.
Date
No.
.. 'Do?. ..
._. .. ,.. . .. .. ... , - .
[Ii
;:.A .'. ... s _."' -•.
Approvals
.•`Raquirod
DofoReceived
or Approved --
,•Yes
No
}vole' coml,cote_
Heoph Depanment-
c;
GrocLng s `i 1
_
T.
Pedeslrlon Protection
(Fence)(Cnnopy)
,. ..._.:
::_.' ..�_._._. _..___... :.:. .... ....
(Conc.I (Masonry) (Welding)
,
Lo, 0--go
'_
--- - - -
Parking
I -
Approvals
(Se,bock & Yards)
Data
Impeclor's
Signature
,
Foundations
Slob
Frame
�l
Energy Insulation
2^1 L �
��
- --- -- -- ---- - - - -- —
Loth, Drywall.
Interior
�s
Z3 ;.
Lail, -Exterior
House Number
Correct & Posed
• �'.�
Fnter on Front
`
-U}CI\lilt-11 Ul1AWR MA I,AR AIION
I herehy aff I Ihol I a mrom p! fIhn Comrorta''s
_L c sc-`Law -I the follnwmg icnson ' (Se cc 7031 i
Rrtsincss arsJ 1 rr fessions Code; Any cite or m fy . •bkb
reyur •s a Jfrrmit to ennel nrcti altrr, irnprn r. Jrnruli,s h,
-- n'%•rri rinv.iiruiti,rr,/irr ,r fir-itc ismmue,ra)ar rryuirrs
thr applica,tf / r sad. prrrnit to /rle a sienrd sr. t,nr.•..t
- tbatbc is licensed pursuant to the prnri.ci,ms .d for (}rrr•
trm tnr's l.ia rncr l.au• (Chapter'J) (cnm.rr,ncrn,q with . "!
tion 7000) of U6 icion 3 of the l3udn,as and 1'.r.Js.+ions
.. �i. CrirleJ ort%m t /.e rs. e.eenrpt therefrom, anJ fbe h-A for the
all,,k"d ,.xunlpfinn: Any r44,ti— of Alelin11•7031.5 by
any appric.rnt font p,rmit stibi ets the applicant m a civil
penalty o/nit nuire`thao fire hundred drlars (5500).J:
I, as owner of the proparty,'dr my eimploye-r wnh
wages as their sole,campensmton, will do the work, and
the structure Is.PoT intended at offered for sole (Sec. 7044)
Business and Professions Cud,: 77,e Contra, tm:c License
I.aw dn,.s nut apply m an owner of pry pr ts. ¢.I huihA
_ or iurprnrc s therr,m anal who dues sucl I •ark. hi—,11 ur
thr,,.gb .his nI,•n.-enrpl1•es, prorid,J,that.-b
;prnnernentr are not inrended or. offered for sale.
"'%vurer rr, the hnilJi nX ni inrprnnenrent is mfd a rtl in onr
year o/ cnnrpl,tiun, fh, awnrr•buildrr will h,tvv tl
l,urdrn of prn..;trg that he did nut build r,, irriprni•r frir
-
..[J 3. os owner of the property, om a+cluawely;rani,.cI
.zing woh licer)sed contractors to cons' vct the prolnct (Sec.
7044) l3uriness a.J Prnfrainns Cod,• 7b, Confracmr's
_._ l.icrnsr fAw does norapply to an nuvt it r/property who
hurldx'nr rmproras 1%rvrs•nri,ad1lwba cwifracts fr ssich
prryv,tt' with a iunfraEtur(aJ lien d purswmt krr the
--...0 err7iir's l emir Z.r7I•J.. _._ - . _..._ ..
I am exemP' under Sec.7. , B &P.C. forrihts
eason
Dote Ow
I" rc teeertner •rr.tee .. ..