HomeMy WebLinkAbout1620A 1621A WORKERS'COMPENSATION DECLARATION � � �
�hereby offirm thar I have a cerrificate ot conseM to self APPLICATI4N FUR BUILDING PERMIT
_ insuro,or a certlfica�e of W(orkers'Compensalion Insuronce,
�7�6�005 2'�9h00]�65ec.3800,lob.C.) lp�B COUNTY OF LOS ANGELES BUILDING AND SAfETY
Poticy o. ompany Nati n11Wi dP
� Certified copy�s hereby furr,�shed. FOR APPLICANT TO FILL IN ADDRESS 586 �lRmitos Place
� Certified copy Is flled wllh fhe co�nty bailding inspec- BUiLDvaG
tion depprtmenf. ADDRE55 $( 1 OS Pla
Da�e $-18's� ApplicantTf� A�IN ��� arr Diamond Bar ZiP 91765 Diamond Bar �
LOCAIITV
CERTIFICATE OF EXEMPT�ON fROM WORKERS' � NO.OF BtOGS. NEAREST
COMPENSATION INSURANCE SixE OF lOi NowOni�oi Ca055 S7.0 10 & GOLCZ2R S rin S
(This saction need not be completed if the permit Is for one TR4CT 42589 B�OGK LOT NO. 74 ���R
hundred dallars�Et00)ar lass.) HWP BOOK PAGE PARCEL
THE ANDII�1 GROUP �`967-9591 use zoN
I ce�tify that�In the performonca of the work for whi[h ihla OWNER NO. ��� ND � � '�'3 �-
permit is issued,I chall not amploy ony person in pny mpnner AODRESSp.O.BOX 3329 �-U �EpAL �
so as ta become subject to Ihe Workars'Compensatian Laws. CON�inONS �
GTY ' ZIP V
� �TICE TO APPUCAN'f:Pf,llofter makinp fhla CarHfitate of ARCHITECTOR�Ve $ZdIl AIA TE`�445-4073 PISTRI�T GROUP CON�ST.^� 1� �OCESSEDBY O�
.emptlon, you ahould become aobject to ihe Workers' ENGiNEBR y NO. f
Compensation provisiona of the labor Code,you must fonh- pDD2e55 314�N. F12St. Arcadia 91006 �� �� �L/Y ,1 U
with comply wifh such provisions or rhis permir ahall be GW.�
deemed revoked � `IZ� ANDIN GROUP TE�� STATISTICAL ClA551fICATION APf. CON�O. fn
LICENSED CONTRACTORS DECLAR4TION CONTRAC70R NO. DWELL.llNi75 Z
UC. ClASS NO. O� �
I herehy nffirm tha�I um licensad undar pmvisions of Chapfar 9 ADDRESS },S d}70V0 No510560 .
(commencing with Section 7000)of Division 3 of the Businass ond ��� SEWER/AAP
Rofessions Code,and my license is in full force and affacf. GIN CV SS B � � YALIDATION
510560 B si°z�eFT1440 s"Toa�s Fo.°ini°Es 1 CO EK
Lice�se Number lic.Class
VALUATION
T� A�'� Ci��� a-18-87 DESCRIPTION OF WORK.S1T1 le famil NEW � ;`=� ()2,�A
Comractor a e App s.67,500
❑1 am exempt undar Sec g e 470 SF � , #�e . a .2�
ALTER �
B.BP.C.for thia reason REPAIR = � 0 2 3 1,1 6
�ate: USE OF
EXISTING B�Dfi. DEMOI ❑ •�+�� 1,1 ��
SignOturE APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT NO. .. DATE Z r3" �� O�,� � �S 7
I hereby affirm rhat I am exempt fram the Gontractor'a ticense AS c'I�JOV2
Law for tha following reason{Section 7031.5, Business and A��RESS FINAL �
�cofeulons CodeJ: , � �y �+�i^�^'
� ! BUIIDING
� I, as ownar of the property, or my employees with Ao�RESS
wag�s as�heir sole compensation,will da the work and ���T� �
ihe atrudure Is not Inronded or offered for sale(Seclion -^� (��,� A
70d4,Bosinesa ond Professions Code). MOVING TEL.
� 1,as owner of the property,am excl�sively conlracting CONiRqCiOR NO. #. .y • e ,�
. with licensed contractors to construct Ihe projecl(Sec- qDORE55
tion)044,Business ond Professions Code). � ,�q q p Q
CONSTRUCTION LENDIMG AGENCY 5[T�BACK YArs� Hwv TaTApSROP.IINE WiOiH
1 hereby affirm thai�here is a construction lending agency fo� FRONT • ^ �>9 9,0 0�
the performance of the work for which this permi�is iasued P.�.
�sa�.aov�,c�.c.�. sioe U 9,1 1 -8 7
v.�.
lender's Nome Clt]�dRk
� 444 S F1oWer .L.A. 90017 231.16 388.50 IDMARef.M
Lendar's Address � P.C.Fee E Permir Fee
� 1 eertify�hat I have read thia applieotion and awte that the laeuance Fe� • ��hnA a/C M ,
= a6ove Informatio ' orrect.I ogree fo comply with all County Invsangorion Fae 399.0�
$ ordinenees an 1 laws reloting l0 6uilding eonatr�tfion, Toeal fee LDM,q parm.M
R and hereby u� ize re sentalivea of this Counry to eMe�
�� upon the - en� ed propeny for inspection pvrposes.
e J SEEREVERSEfORiXPIANATORYLANGUAGE
� Signo App icont or Agenl pa � . .
P4AtdS T4 APatICANT IMSPEC40R'S NOT[5 . O�t'.N!{N-HUILU1fK UkCI.AHAIlO11' .
' - _ . �h y �� f. i. i�,� . r rc;r.� .
To: . � Rr#urmed . ' Gc LnN:�� t,.e fn� i .- Oti ;
—�- RPProved Ba _.-� !!r 1.��l.nr( d Inv car� i r ntti� lich
Na.� � Dete Nm � Pale .. .. � � � � - rcy x ,..p� t� ,,.rn� i rin�r, r/ � ;dr t:�h.
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i . - . . 8aquired . DafeReeeiwd ..... . ��.. . . � � arsyappli.�n1(orapr>v+eitvuh��. fslGeapjl�:enlrn,e;:ri/
ApProvals . or Appravad pvnrr/tv nlnot nrnn (bsrs/ �/ nJr�d J ll�rr�/SSOQJ.J.
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__.�__.-_____�___ ._..—_.._.__�._�. . . . '; �� 1.os owner o4 rhe p�o..F�rry .�� y er�r.lov^es w,�l.
VJ.�Ie.Cer.�#Icore �� _ .. . � - _ , w�9es as theu sole coinpe ���on,wdl do rhe wo•� cr.j
� �` �� thc srcuUu�e�s r o � te�ded o�o{ie�ed fo �� Sc,. �dd?
�i Rc��aLh Department . I . . . . -— . . .. (3rurness nnd Pr i/<.ssror:.v Codc:'1 he(,int a�fur's l.uc nsv
�. . �_--1 . . I.ae<�dnea xa�upp/v In un.naner nj prnrrrh�n�b,�Gurl�l,v
Pre Depnnr�en• � � —" nr�»+prni rs thrrrnn,and:i/� d i. r I b l r�. !/rr
„�-�,�,_� . ' . . . �tlrrnu,�lr�his oa n r�npiny . j� i 1 U c 1
G,�,�.�y . � yrnr emenls orP nna �n�e �!d r /J -�d f � 1
� �. �� ' � Inne�rr,tf�rbue[dix,�nrnmJ r�cmenr � lii tl n -i.
�6eelogicol � Veur of cnn:Jdetenn. !hr nu�ne�rvbailJ il7 1 a [{�
j _� _ _ '. . . • � hurden n!p�'or�ix,�thn�J�a,lyd nof hu:ld rrr mrt,r.,�v for
�Ped-s . G +�crlon ! . . _ . . �f' P P�-re n(sale/. � �
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f_ncrl .. � usov.re�rofthep (rly.�o e � r.��.yco..tnc�
� r"mg w I-Fcen c�ci co«Irnc��; �c..nsrr� t � �,ro�e � ��a�.:.
Soecia•.inspection . .. . . . � 7044)�Iiusiness end Proicasr��ns Cuder 77r Cnr�truct��r's
ii:enc,1(l�,psonrv)(We;ding) � .. . . � l.icensc l,uu�dues root apph�tn,��i r,u.vrer nf p*nperll'u-L+n
! � - . . _ . .. Auifds n�imprmrs ilrre��n,und ubn ronlruc'1.c/ar.er�rls
� � �prnjc�t;u�et1 0��3n�rnctrr(v1/i�rr�A,�d pr�r.tu�u�t tu N�e
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