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
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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'
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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
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Sc:rF ck�&Yords; l� �y�S7� .�/� '- . �
Faundaiions .� �� � � . � . �—._..`..:
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�Co�r.e i&Posted �
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Enter nn Front � � �
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