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HomeMy WebLinkAbout0565A 0566A (4) WORKERS'COMPENSATION DECLARATION - � � �� � � � '� ..,.. � I hereby affirm thot I have a certificate of consenf to self P�-an �3�����f�w�'o� �o#\ ���'' � � insure,or o certifimte of Workers'Compensation Insuronce, $1eV. �.' � � L��I NG������E-1�MIT or a certified copy thereo4(Sec.3800,Lab.C.) � � �uq��45-i na C`i3�mpany Ar�tna - COUNTY OF LOS ANGELES BUIiDING dND SAFETY Certified copy is hereby furnished. FOR APPLICANT TO FILL IN su��o�tdc, 243$O DdY'rlri DY'1V2 e� nooaess �S� Ceriified copy is filed with ihe counly huilding inspec- BUIIDING tion deparfinenf. ADDRESS zL� LOCAIITY NEAftEST Dare 5/29/85 f�pplican� THE ANDED7 GROUP arr Diamond Bar z�a 91765 cRoss sT. io & Golden� S rin s CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OP BLDGS. ASSESSOR COMPENSATION INSURANCE - ' ' SIZE OF LOT NOW ON LOT � MAP BOOK ' PAGE PARCEL (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. 43 f USE ZONE NOAP � hundred dallars($100)or�less.) TEL �], - SPECIAL � I certify ihat in the performante of ihe work for which this OWNER �: ��� �i�� No957-9541 CONDiTIONS :1. permit is issued,I shall nof emplay any person in any manner ' DISTRICT GROUP 7YPE FIRE PROCESSED BY �' so as to become subjec�to ihe Workers'Compensation Lows. ADDRE55 1074 Park View DriV2� coNST z � c�Tv covina Z1P 91722 � '3 � s` Dafe Applicanf STA715TICALCLASSIFICATION - APT. NDO. � NOTICE TO APPLICANT: If, afrer making this Certifimte of ARCHiTECT�� & �1SSa� TE�45-4073 �� ��� � ..«"^,amption, you should beCome 5ubject to th¢ Workers' ENGINEER Y NE�. CtA55 NO. DWELL.UNITS � mpensation provisions of fhe Labor Code,you must forth- AD�RESS 3]_Q N. ZSt. AV2Y1L12 Arcadia SEWER MAP� � � ith tomply wifh such provisions or this permit shall he G� deemed revoked. CONTRAC�R`- �1er Np, BK PG, VALIDATION � � LICENSED CONTRACTORS DECLARATION - I hereby affirm ihat I pm licensed under provisions of Chapfer 9 AD�RE55 r`�'a37158Q VALUATION � (commencing with Section 7000)of Division9 of the Business and LIC. B c r� Professions Code,and my license�s in full force and effeU. CITY CLASS $ ( � •-'G"�'"ft SQ.FT. 4 NO.OF �NO.OF � CHECK , }`�' a o a o'2'� ucense Number 371580 lic.Class B size ��o� s-oRies F�,rniues orve Conrracro� TT-1F. ANnFTT GRnilPpare �i,/2A/R5 DESCRIPTION OF WORK 5111(�. F�tt. ReS. New (� S ; a r 2�,R� ❑I am exempt under Sec. �idra e — L'�" qDDR � FINAL / " `���.L�.`f� ( u B.&P.C.for this reason DATE �';��'t,/'�5' � REPAIR � G C2 i l"�J USE OF s Date: �EMOL ❑ gy AL h�d�4� ��i°�`i;���l � EXISTING BLDG. f $ignaiure APP�ICANT TEL. OWNER-BUILDER DECLARATION PR�NT� No. �r� � " 3 � � � I here6y affirm ihat I om exempt from�fhe CoMrocror's License ► �v r n Law for the following reason(Section 7031.5,Business and nooae55 , ._ ,., _.. � C)�V C _ Professions Code): . pgE (� BUIL�ING . .. •��Cij U�,��` ���r � I, os owner of the properfy, or my employees with ADDRESS wages as�heir sole compensation,will do the work and 7` fhe siructure is not iniended or offered for sale(Section LOCALITY u`fi,f ccJ 2'i 7044,Business and Professions Code). MOVING TEL. � I,os owner of}he property,am exclusively coniracting CONTRACTOR NO. with licensed controctors fo mnstruct fhe proje<t(Sec- qDDRESS � fion 7044,Business ond Professions CodeJ. � RE4UIRED iOTAL SETBACK FROM E%IST. CONSTRUCTION LENDING AGENCY� SET BACK YAeo Hwv pROP.uN WiDTH , I hereby affirm ihot there is a consiruction lending agen<y for FRON7 the performance of ihe work for which ihis permit is issued p,�, (Se<.3097,Civ.C.). SIDE Lender's Name �nt����' I�"I171015 P��� $ 399 Park Ave., N.Y: 10043 P.c.Fee$ Pe�m��Fea 379.50 Lender's Address � I certif that I have d this e issuance Fee Z�.rJ� y plication and state that�the � above information s co ect. ag ee to comply with all Co ty Invesrigarion Fee 7 ordinances and tat ws r�o building constru on, totcl Fee aL� Q.Gz? and hereby au ori repr toT es of this County to nt � upon ihe abov - tione op rty fw inspedi�u os s �� - � - � . . . . ., a � � �S , SEE REVERSE FOR EJ(PLANATORY UNGUAGE Signafure of Applico or Ageni D te �s �.,.__ - .. .. .. , , ... ..�..�<,�....,..,... .�-.-..-e a..e..� . , :�;N i 3L kJL R x.t'.�,y12A.1 L>C�i .. .: . . . . ": �� � Z . '�� PL�3d'S'aQ:@P�SICAPIT,.'.... ..�. I � Ih',SPECTO�'S NQTE" . � � , � . � �...� .T._.�,..,-..,.....P,......-�.,.-..... ,,.,._,.,......o.,_...,,�..-..`..,.-,a....,.._ � . �,..-,...�....m� tie eb�aff r-n Inat ❑m exempt from the Confiac or s To:�_� Returned —' L��anse Law for h to Icwng reason (Sec 7031.Sj .OpprovmeP �------- ,�ia�srec pndYeFe sCo�lefny xyorco,s+a uhsc7 ;��_--_-�aYe� _-�Tdo.�, P?e�fe �__._ _ � _._ . ., r:.su�es n p5� �... �axs r ct �er.c �,c�esys risl, � -- — �— aa� tru..e.r..,�a ,tn xts xcsi rto ce aiso eq ssres i . � � �I I . ' -� - . . xs f cer,or s*�,spernric b'ne hror u ozs�t5e oso-o- � . _ .. . .._ .. �ro1-c� r c L� S ....... .. . .. �_, � . . .-. � � , ... .-. tra Po . 1 s.�wse La:u'(Ch.+j-iar 9I(cor.me:ui�r,sih�rtc_ ..... . ,,... . ,., .� �.-� . . . . .. .... ��_ . � � � � � � . — . �"-terr�i OfJJ of 7'is s nn j o !be 13,esztin.rs an�d rnfessictts ' . � ���^ � :1 J rsr tnat exempt���bei e{rr,m and tfia G?sis jor tha � �,�---. . - ---- - . c11 y x�._eoxfif �r A y . ..a..o..�f Section.l�31.5 bg, �,,.:'��•�•••��••.•_••'�M-• � °�Fa,uirea �etP Siacmevaz�' f �� ... .. , _.. ., •� ..,. .... ., ...n�-i a� xcamt � ..�-�a Y ubj cis Sha ap6f-t¢nt�a�c�civil ��� Fa ,.�'ewul5 .. . �- orPippraved — . � —_._ �__ �herc�.1'uaso �s o�i e ro arte�.Yzrra Imn.or�ees.�a�: dG3 ih0 - � � ��� — � — .�.,�-wages as rhE�r sole-com ansa"o;wi!I do ihe work,�and �I VVaFer�*c<tc� � . . I . . . :.....- . ��� p ,. .. -.... ... . � '-� � ��'� � � ' � ' ihe siructure s not intended cr oi4ered for sale(5ec?044) , ..�:. � . . .. ;... `. _. � :"" . �user.ess ar.a'Pr t nrs C�e ..a� ora ac��:'c:.dcense Heclih Department : -.. . .- -- - _;,au rk:ns not u�jly z�a a�e f p �h �tv wbn builds 1 . . : - �i�r hr�- sY3er x�a a.ufu� �'ncs cbaor�a!msel,for i D:,�, :-n�nt : I . � .. �,�.,. .. .I - - . aS>rx,�q ss oum � rhto s � �d Pr s.s 1 �. _ � rGr_ui�g � - ..��_. -. ..:�. — :. . ¢ro sKe--ts arc nor� n 3 fer�S o a4� . ' '+ou rr 5 c¢ da o np5 c -� . � o!l - tl � -.. �� � � . —_. . _ . ryecr >f conyle r o �a b C +.4 � tie GE'OIOGI< I 5 W �bs r 5--.�t �' c.F a r� .,, elos �7eaesPr es�Protecticn � . � -- . =1 prerpose f IeJ . . . . . �(Fsnce)(Cancay) I � -- . � ..� -]� 1 eso n o '�� o �.t) am e lus tisly contra< �� � . � � - �---�----�—�- . . - -'�'- i ng , �'Jcersed cc�ircct to c?���s1,uc'iL-e pro ec7(Sr. i � � ��' � � . . � ... . ' . - . - , 7`7 . r z .1 r. �,as s�G1>d. � oa?ructor s ��Ilnsoaaon � ,.., — �fscrs ¢u�Lo nn6 nX nr:ou� , ri� .cfin (Conc.�(��Ncsonry}(Y+leldine) "-' _. ..:�� .. �._ . .. . �1' f`".�,,. . :5ss�fda.�r.,���.,,a);,ouc.,.l?_r er,u_��rchr pnne,.cts for sucb � . -'� . � . . .. ....,. . -- � J CS tt. � C.l'YTIf!1' 1 'll. . f�_T5:32rt: `en L)Je Lo5 Draincge .� .. .. � ... . ... .. .. ..., .. . ...� ` � . . . __' '— F.�. �. isacxor. .. �. I:,e.y. , . �arkina � �— - . � . � . . . . - � I am er.emp��.der Sec�_._,0.&p.r'f .ri�ie 1 i� —� � _ _ — _ ���So, __---- ---- � � �- . . .— , -- _ ._—_— Datn . . . . .. Owner.�... , _.. �_�:--...�_- --___ � �fFrc=,�eis � ',Jcgv � ! s eC.ors56 ncivre '� I . . . -�-�----...��..__� . -.-._.... _ .,:._ .,.._. . � `'� 9 , iF�4 �,'3Ct'e'}FSa;c'9Y6S � . LOCO�T_�=_ _. __� __I . . . . ..... '�' . , . �cs�•�G:�g vc,z�� r r.y. e_��1�"�,„_..,._,--` _ � _ r S�`�...4 — �—� -- --- — Foundat'ens "\0 6 j . . . . .. slab — ��`��.4�..j..—_L_�`,„r'4t-tCw`�-� —� � --- — — - i ^ , :Framc ,`�.�J�r!f?� �,:�si;>:�.c �. .� . .� .. . , . . IEne�cy lnsula^:on 1��,i���'° �tir,� — .. �.� — � �.�—_� � __ _ �_ .—. ..— �---- �.T� �e LI a9hi0 ywal:- �I�r�)�dE,T. � - . . ..._.. . ... . . ... ini •ior _ -� -,Z`5 � {SF�x!� : �—. ... . . ... .:,.. _.. .. , ... -� . . .—.� . ., o r �^ r� _— -�_��_ ..� ; _.... _ .. I Laih-Exte•ior € 7��.5;`r 3 .•%" � � .�. ,. . , . .. . _ - �. � : � �� _ _ ---- - -- — ��Hcu�se�lV�um�b�e- � ` � . � � .:. � „ .�.��., .:'�. .�, ,. , Corrl ect&Po�;ed . . .-�. . . � ,.. ..,. .. � . ,F;�_—.. —i---d--.— �—. . :` _. � � �' ��__._� _ - E-PE�4���•��� . . . . ....._. - • .. - -� . �� � _�___ . . � .._ .._... --— . . . . � � ___ ___�_�..�__._._�__ ..�_.—_.__.�,_ .�