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HomeMy WebLinkAbout1741A � WORKERS'COMPENSATION DECLARATION ` " � , , �e�eeY affirm �hai I have a tertificate of consent to self APPLICATION FOR BUILDING PERMIT insure,or a certificate of Workers'Compensation Insuronce, or a cenified co �hereof(Sec.3800,Lab.C.) � a3�Wc005-2��-0016� NatiOriWide 1/B �OUNTY OF LOS ANGELES BUILDING AND SAFETY o�cy Na. ompany � Cenified copy is hereby furnished. FpR APPLICANT TO FILL IN BUILDING ADDRESS 9 OS Place r"�'1 Cerrified copy is filed with the coonty bullding Inspec- BUILDING �� fion depar�ment. AO�RE55 596 PsmitAs PlaCe oo,e 7-30-87 aaPi��a„r TF� ANDEN GROUP c�Tv Diamond Bar Z1P 91765 �ocn��Tr Diamond Bar CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. rvEqREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT cRoss sr.Diarnond Bar Blvd & Golden Springs (This secrion nead not be completad if the permit is for one T�,�� 425'7g BLOCK LOT NO.18 �ESSOR hundred dollars(5�00)or less.) MAP BOOIG PAGE PARCEL Tf�' USE ZONE NJ+F i certify that in the performance of�he work for which this OwNER nl0 — �M� �, �1�' li permit is issued,I shall no1 employ any person in o�y manner AP�RESS P•�• �X 3329 SPECIAL �, So 0510 become sobjed lo the Workeri Compensatian Lawe. SO CIU CONDITIONS � a1r ovina z�P 91722 � �'�ote Applicant LL^ JOTICE TO APPLICANT: If, after making�this Cerfifimte of ARCHITECT OR TEL. �ISTRICT GROUP ttPE FIRE PROCESSE�BY � Exemp�ion, you should 6ecome aubject ta fhe Workeis' ENGINEER Dave 52111 ATA No.445-4073 ,(� ? CONST. ZONE r F— Compensation pravisions of the Lobor Code,you must forth• qpoae55 314 N. F1Y'St� Arcadia 91006 ��O R�J � �- rna\Of�e W ith comply ih such provisians or this permit shall be TEt. � deamed revaked. � STATI571CAL CL4SSIFICATION APT. CONDO. (q CON7RAGTOR ND. ,�,.� LICENSED CONTRACTORS DECLARATION CLA55 NO. ��' OWEIt.UNITS��' �. Z� LIC. I hereby affirm Iho�I om litensed under provisions of Chapter 9 i,�ORE55 � a�OV2 No 510560 (tommenting with Section 7000)of Division 3 of fhe Business and ��� SEWER MAP Professions Code,and my license is in full force and effect. CITY CLA55 B eK � VALIDATION Li[BnSe Numb6r 510560 ���,CIa55 B sieFT .1535 NO.OF NO OF 1 GHECK STORIES 2 FAMILIES ONE vnwnnoN cor+voao�'�'� A�IN G�UP Date�'30-$� �SCRIPTION OF WORK SI. le famil NEW s �8��g Q ADD ,❑1 am exempt under Seo e F q�rER � 8.8P.C.for fhis reoson REPAIR s �1 7 4,1 A � Date: USE OF � DEMOL E%ISTING BtOG. �� �.� �.Z.� Signafure APPUGANT TEL. FINAL . OWNER-BUILOER DECLARATION PRiNi NO. DATE ��Z �� I •2 6 0.6 1 I hereby affirm�hat I am exempt from fhe Comractvr's License AS �OVe Law for iha fallowing reason(Sec�ion 7031.5, Business and AD�RE55 p�ryh� � � a����,�.� � - /�''ro4essions CodeJ: 6y rtr-C JBUIIDING 0 9,1 b—8 7 I, os owner of Ihe properiy, or my employees with A�DRESS wages os their wle compensation,will do the work and `�`T� � . ' tha ahucture is not intended or offered far wle(Seclion 7014,B�siness and Professians Code). - MOViNG TEL. � I,as owner of the propery,om exclusively conlracti�g 0�1TRACTOR NO. with licansed comrpcfors ro consiruct the project(Seo- ADDRE55 tion 7044,Businass ond Profeuions Code�. CONSTRUQION LENDING AGENCY SE BACK �ARD NWY T�TApRpP.LWE WIDTH �� rI U,L A I hereby affirm thal ihere is a conatruclian lending ogency for FRONT the performonce of�he work{or which�his pe�mit is issued F.L. � a • • • •-� (Sec 3097,Civ.C.�. SIDE Lender's Name Citibank r�. I o 4 1 2 5 0 444 S. Flc�wer, L.A. 90071 P.c F�s 2 60.61� va,mu F.. 402.00 �nnn ee+.+r • •:q 1 2�D o Lender's Address , 0 9.1 6�-8 7 I ceriify�hat I have read Ihis applim�ion and state fhm the � ianuan<a Fee 1 Q�•5 p LDMA PiC M . � above informatio corroU.I ogree�o comply with all Couny inveargauon Fee j ordinaoces a te laws relating to boilding constroction, to�al Fea 412.$O � tMM Ve�m.N and hereby orize represenlotivas ot fhis County fo enfer i upo he v e ' operry for iaspetlion rposes. L DMA � . {�/� - $75.OQ $35.00 p SEE R6VERSE FOR lXPUNATORY LANGUAGF Signoture of Applicant o�Agen� ppte . - OWNh:IZ.};lf]I.DLK UISQAILAl1QN PtAP15 TO APPLICANT IN6PECTOR'5 NOTES � � �he�eby cflirrn thai i a exemp�tron,;hc i�,��,,,�:a�:io,'s To: R�lurned i . � � �Llce �:P Lcr�.v +�r �I-e `oll �nq rr.r, �,� �'Snc �pat.5� Approved - ---- � H� .�❑ d Pr f s . ( d lnv �ft t�. f l Nn. Dat .u. No 4ole ...... ' rcq :r / n ;t t al t !t . t �,�rt�n�l.d .____�__._..._._____ ---s___.__ .. __— � . . --- � ur p y�1 u-t p t t .t�.n �n ra yx�rer ._�..�. 1 . � tht u//l r1 . !/ et /!. < .l rrr r �.. ...._{..._�.�. _.__—_._.. . . .tl�e L. ! .n�dj . t r rl.p n f r1 <. ,- :, . . . -- . tr i .1� - l,e� {(J pt }I(- �ni ir�?l-1' �- ----f--�--.— --�--- tf, .Otlll/ (U r- n 3 /ti.. R �e ia rnd 1 r 1 cs� s I u� �� . _ ' . � . . � - � CuJcf nr eGJt/ oc<�.rcnepe tb r�Jr an!11 ! s�J tl o -- — a[le,qed v.zcn�pt�,irz.Anl.�.���Jatinn rf.Srchu�:.U31.�hti. . .. . . � q ' d �ata 4feeeived � � u+n�upplia�nl/r n pernut.w�hjcats�bc a</:Tliaral to a cirr7 re App o als i o A ved . . � 1'enaltt /not � r fha ( 1 �l ed d ltmc 155qp11' . Vns N PV�P —_`�_... �._ ...�.,._. �' . . . 1 . I t S'ow P !ILp P. � ��/ Or �lln),p F ._..__:�--_=�__:��. W�i., (. �,�.r �� W �� � .. . � _ . wag.s a,th�lr sole ccmpe sa��on,.vil d< ihe w ... Ihe s+�uc� e is �t iended o- 4!.�{f y�l. (Sec 70a4} Heal-h Deuanmen� � � � - li�csin�ssan�Pr/�asrnaa(�!e %! (. H¢t�rt! .re l.aro dne.a not ppf�tn un r . o(pr p ov ioh, h lds F.,t�Ger..t �er�� `�i� � — �r nnprai�rs U re,�n�and u! d c. «1 ,rE:binni.//o-'- - � lbrnp,�h Ars�oa n arrcpfu��. Jr� rA J tl t au.! f. ,rodn9 � . .� � - � . .. � . . . (+roee�nen�� are not ixlc d.d r� ff nd 1� .+ lv.1l ' � � . bniee�rr,eheb !d ,y � p te flu t,>ont Cealey�col � P�'�r a/cnn�fl_t"n t_e� un [ 1!J !! I>aie the _ _ hurden n(��rr r�nX tbat 1��rl1A m�l F��ht nr impr_ f.o Pedwsfr ,Pro+x+re��T--. . e/c purpo_ec af.enle). �Penc�)ICannPY) � � . . . . � Gnq�w ih I censod onnncto s��o�cbn tr�_�d.�pr�e f�(Sec. . . . . 70a41/3:�sinrs.s and Prn/essionx CoJe: lAn Cuntr�rror's ,�pec I I pectior-, 1a e ri.de l,u�r d .s n I a ! �Con.1 IM senrvl(Weldin�l� . _ .. � . .pf 1 d un �u•avr nf properh u�hn �ha!lti nr nrn� n es tdrere��rc,u i�1 61 n cnretrorRs Jua surb Lot Drain . . � - _. . pr jectc�u�itb a onntrartnr(sJ !i<rnsed f�o.rsai�at I�n tGa � " ._ � � . Cnntm�-tnr's I,icenRn l.au•1. � � Pcrbng � � �.__ I am exempi undcr5ac-�,�.9.dP.C.fo��ri�s ���reoson�. _T � U4�c . Own �_ Approvals Date lazpesfor's Signatu�e � � - �INSPECTOiYS NOTES —:—._---.—'=_—_—=��_rv. � Sc:rF ck�&Yords; l� �y�S7� .�/� '- . � Faundaiions .� �� � � . � . �—._..`..: . �,' - -- -�-_._____- � ��f � Sioh F,a,,� r g � __��_` ____ _ —_ —____--- e„e-oY��s�i�,�o�, /> /4 � /72.�JAS i�,�r,:u,,,wan- - �f�' --- -- i�rer,or 1 J7 ff f �._�`r,�i� __._....,_ Lorh.-Ex+er�or � V ��vIr�-�.. � �^ � �-'. � —L��'.��_ ._..�� - � Houu:•N��.�6e. ..... .. . . . . _ . . _ .. . . . . .— _ �Co�r.e i&Posted � Final I . . . . _. . . . Enter nn Front � � � ' _ . . , . . . , , . . � �` �f=..-