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HomeMy WebLinkAbout0766A �� , WORKERS'COMPENSATION DECLARATION ' �-' �. � � �- - I hereby affirm �haf I have a�e„�,��o,e af�o�5e��,o ge�f �--�� ���APPLICATION � FQR�:�BUILDING PERMIT �� � �1 �. insure,or a cerhf�cofe of Workers'Compensation Insuronce, � o�a certified copy thereof(Sec.3800,Lab.C.) �� ' ��� � � - � - -- . Poucy r�,3WCa05-27 3,fy Natioxiwide COUNTY OF l05 ANGELES BUILDING AND SAFETY ❑ Pv' r FOR APPUCANT TO FILL IN nooRess 596 Armitos Place Certified co is hereb fvrnished. ❑,� Certified copy is filed with Ihe county building inspec- � BUIIDMG � � fion deportment' ADDRESS � S96 AT[R1LOS Place oa+e ��8�87 AppliwM THE ANpEN GROUP �irr Diamond Bar ziv 91Z65 �ocnurv Diamond Bar "CER7IFICATE OF fXEMPTION FROM WORKERS' � - � � -NO.OF BtDGS. � � . NE,wtESi Di.amond�Bar-,Blvd./Golden'S rin S � COMPENSATION INSURANCE � -� 5¢E OP LO7 NOW ON LOT � CROSS SL P P (TNis settion need not be mmplered i5 fhe permil is for one TRACT BLOCK LOT NO. Mqp�gOpK � PAGE PARCEI hundreE�dallors(E100)or less.) ., . ' ��' US ONE MRP y � p work for which�h�s ow�vee THE ANDEN GRO No. - /� -� } I certif�that n Ihe erformance of the �� �� permit is issued,I shall not emploY any par5on in any mdnner � SPECIAL - - � � d so as to 6e[ome subject to}he Workers'�Compenmtion Laws. � � ADDRE55--- �p.Da $OX 3 Z . � �Dl.� CONDITIONS � u /'��.'y . � , . , �.'. . �� � GTY Covina ZIP . . . . . . _ . . . .. � � ' - AppliCaM� q2�HRECT OR TEL. � �..iTICE TO APPUCANT: If, after making ihis Certifiwfe of ENGiNEER Dave $ZdR AIA � No.445-4073 DISTRICi GROUP iYPF . FIRE PROCESSED BY . Exemption, yo� should become subjed to�Ih¢ Workers' -- CONST. �J ZO Compensotion provisions of the Labor Code,you must forth- 18 �-?f fv W ADDRE55 3�-�i N. First Arcadia 91006 - - d with.comply�with such provisions or lhis permib shall be � - � TE�. STaTiSiKnl ClaS IG710N � APT. CONDO. � Z desmed revoked. � � � ' CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION �� - � �� - �i�, - - ttA55 NO. �DWell.UNiTS I hereby affirm tFwt I om licensed under provisions of Chapler 9 ADDRESS $�II}e, gS d OV NO. j ��R�P (commencing with Sec�ion 7000)of Division 3 of ihe Business and . _ . . . . _... UC � � � Professions Code,and my license is in full force and effect. CITY CLA55 - BK ��:� , - YAUDAiION � 50.FT. NO.OF NO.OF CHECK � - License Number S1O$f)O ��c.Closs' B SIZE ]_ 570RIE5 Z FAMIlIES Z ONE .. - - � VALUATION . . ' . . . . Co�tmcta� THE ANDEN GROU�ja}Q ��B�HJ DESC2IPTIONOPWORK 1 1 NEw : .�V�-B SF ADD ❑I am exempt under Sec. - _ ❑ . ALTER B.&P.C.for ihis reason � - REpq�p � f � �� � � � -� . ... . Dote: USE Of . EXISTING BLDG. PE� . . . Signature � �� � APP�iUNT TEi FiNp� �`�0%�,b A � OWNER-BUIIDER DECLARATION PRiNi THE ANDEN GROUP NO. DATE ��� �� - I hereby affirm that I am exempt from the Conimc�or's license � � ��� � � - - � � �� . #� . � e .� � for the following reason(Seclion 7031.5,Business and A�oRE55 Same as .above flNAI � � �essions Code): -. ... . . . . . .. .. pRe N 81' �'Ls � �I m�•7(1.Z 5 � �-� BUILDING I, as owner of fhe proparty, or my employees wifh ADORE55 � _ wagei as their wle compensalion,wiUdo ihe work nnd � - ' _• o a�o�]�,[5� the structure is not infended or offered for wle(Section ��`��TY � ; . � � -7044,�Business and Professions Code). � � MOViNG -� 7EL �� �� -�� � �� � ��;� � ']��'� � I,as owner of the property,am exclusively conlracting ��TRACTOR NO. � �- with licensed contractors ro consiruct the pro�act(Sec- -� qoDRE55 � � tion 7044,Business and Professions Code). , -� � � � � � CONSTRUCTION LENDING AGENCY ��- - SEQgq� YARD HWV T�TApR�tWE WID7H � . . I hereby affirm that there is a construction lending agency for FROM � � the�performance of the work for whith�his permil is issoed P.L � �� - � (Sac 3097,Civ.C.). SIOE . ' Lender'sName Citibank � � �� � - - P'�' � � � - -- � � � � - ��� � - � L�M4 Ref.M . �eoder'si>ddress 444 S. Flower, L.A. 90071 P�ke5 7ermitFee 63.75 ' .I certify ihaf I have read this opplimtion ond stafe ihat ihe - Issuonca Fee IDMA P/C f � obove information is mrrect.I ogree ro camply with all Counry Inveatigation Fee � �� ordinantes a tate laws relating to building consfruction. . . - � Tomifm �- tDAM�Perm.�N - - � � and hereb o�ize representatives of fhis Coun�y to enfer upon th b ' ned property for inspection urposes. � SEE REYERSE�FOR EXP�1INATORY LANGUAGE 'O _ i -..... .Signatura of Appliconf or Agen1 . - . . re . . .. . . .. ... . . .. . ... . . . � PLANS TO APPUCANT INSPECTOR'S NOTES - � • � �OR'NF,R-BUILDER pECLARATION _ . . I hereby affirm that I am exempt fromlhe Convaxtois � To: � � �� RetYrrtad � - � License Low for ihe foll'owing reoson. (Sec. 7031.5) Approvod Business axd ProJessions Code:Axy c+ty or rouaty wbich � . No. Dnh �� Nm ��- -Dnto- � � - ' . requires a permit to copstruct.alter,imfrove,demolisb, .. . . . . ar repoiraxy structure,prior to iis issuaace,alsa regeires . ; � , . , � . dhe applicant for sucb perxsit ta file a signed stater�sent _ tb¢t he is lic¢nsed persuaxt to tbe provi�iona oJ the Co»- � . _ .� � .. . � trartor's Licease Law/CdaQter 9J(co�rtmenting witb Sec- , tion 7000)oJ Division 3 oj tbe Business and Professionr �-���. � � . � , . �, � , � . � - . �����Codef or dbat he is exempi tberefrom and ehe 6asu/or tbe � a!leged e.zempNon.Axy violatson nf Seciion]031.5 by �. " �' � - "� "�Raqutrbd p�e Rscelred � � � � � - � � any applicant for a permit sabjects tbe applicant to a ciui! Approrols .or pppiovad �penalty of not more Lbari five buxdred do!lars(35�0).)r ' � Yas No � - � - � - - � � � � � ❑ I,os owner of fhe properFy,-or my employees witk Waler Certificate � � . .. . . �- .. wages as�heir sole compensotion,will do the wo�k,and � � � � � � ihe structvre is�ol intended or offared foi sale(Sec.7044) Hephh Deportmenf . . . . � _. .. . � � . � � � . ... ._ - Business axrt Pr/essions Code:The Coedrac6ori LiceAse Law does not apply to an owner of property wbo buiJds FirC Deportment � . _ . � � � or improves thereon,axd who does sucb work himsel , �- � � � . � - " - �througb bu�own enployees,provided�ihat such . Groding . , ' . . �� provements are not ixtended or.offered Jor sale. If, � , -� � ' �' � bowener,tbe bvilding or impmvement is sold witbix oxe � �� � � �- �� -� � � � �� � qear of completion, tbe owner•builder�will haue tbe Geological . . . . � ,' � � �� � bssrdex oJDmvirtg tbat be did nat build or�improve for Padesirion Wotection. . . . � . . , tbeQurpose ofaaleJ. - � (Fence)(CanoPY) . ..... � ... ...� � � . . � . .- �.�... . ❑ �I,�as awner of the property,om exclusively taMror � ting with licensed controdors to construn the project(Sec. � � � - - - � �-�� - 7044)Business and Professions Cnde:The Coxtractnr's Special Inspeclion � �� � . (Conc.�(Masonry)(Welding) � Licerose Law does nod apply to.an.owner of property wbn ��� � � - � � � � bssi[ds or impraves tbereort,mnd wbo ronlracts f r sucb Lot Drainage � . . � . ._ projects wltA¢cimtrotlor(sJ litensed pursuant to the � .. �Contractor's-Licease LawJ. � �� � . Parking . � . . - . - . . � . � . ❑ I am eaempt under Sec. ,B•8P•C.for�bis reoson �. . . � . � Date Owner Approvals Dato Inspector's Signaturo, . . . . INSPECTOR'SNOTES � Lamtion— (Setback 8 Vords) - ' �" Foundations � . . . . . - . . . � . Slab t Ct _ . . . . .. � . ._ . . . .. . � . 6 Frame . . . . . . . Energy Insulation . � - � - � � � . - . . . � . . Lath/Drywoll— - . . . ... . ... . Inlerior - - � �� � � � - Lath-Exterior ' . . . � � � . � � . . . �� . � .-. ' . House Number— . . . .- -.. . . . �� � . . . . " . . . ... Cvrrect&Posted � Pinal-- � . .. . .,. .. . . . . . . . En1er on Front � � � � , � _`. . ` . � � .�-�. � ��-, , .. � ( �K �