HomeMy WebLinkAbout0718A WORKERS'COMPENSATION�ECLARATION . . ,+, f�
I hereby affirm that 1 have a«,,,t��o��of�o�,���,o se�, ApPLICATION F4R BUILDING PERMIT `�� �
insure,or a certificate of Workera'Compensation Insoranca, L�
� or c certifiad copy thereof(Sec.3800,lob.C.)
aoi��o 005-279—OQo���i�ationwide 3/S COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is hereby furnished. FOR APPLICANT TD FILL IN nooRess 597 Armitos Place
� Cerfified copy is filed wilh ihe county building inspec- BUIIOING
fion depar�menr. aooaess 597 Ai^tnitos Place .
oaie ��8�87 Applican� T�� �EN GROUP ciTv Diamond Bar ZiP 91765 . ��iT� Diamond Sar
CERTIFICATE OF EXEMPTION FROM WORKERS'. NO.OF BlDGS. NFAREST
COMPENSATION INSURANCE Si2E OF 10T NOW ON�OT cRoss sT. Diamond Bar $ZVCl./Golden $ T1R 3
(This section need not be completed if tha permit fs for one Ty�C7 BLOCK LOT NO. . ^�FSSOR .
hundred dollars(E100)or less.) MAP BOOK PAGE PARCEt
TE�' USE ZONE 1MP r/
I wrti4y that in the parformance of the work tor whlch ihis �NER � 0 ND. � — 1 NO. ,�/3
pe�mitisissued,lshallnotemployanypersoninanymonner qODRE55 P•�• BOX 3329 SPECIAL �
so as lo become subjecf to the Worken'Compensation Laws. CONDITIONS Q
���e A I�conf ciTr Covina z�P 1722 . � �+'�
.OTICE TO APMICANT;�f, after moking�fhis Cenificare of ENG�NEER �R � N� WSTRIQ GROUP IYPE FIRE Oc�SSED Bv p
Exemp�ion, you ahould 6ecome subjec� to the Workers' — 2 CO 2 �—
Compensaiion provisions of the la6or Code,yov must fonh- qDDRESS 314 N. FiLSt� Arcadia 91006 �O �—r7 � O.`p�(1 W
with comply with such provisions or Ihis permit shall be - � � p„�
deemed revoked. � 1E�� STATISTICAL CLASSIFICATIDN AP7. CONDO. �
CONTRACTOR � NO. Z
LICENSED CONTRACTORS DECLARATION ���,� 0.A55 NO. DWELt.UNITS .
I hareby affirm rhat I am licensed under provisions of Chopter9 A�DRE55 S2Ale aS above� No, 510560
(tommenting with$eclion 7000)of Division 3 of the Business ond ���, ��R�P
Professions Code,and my license is in full force and effect CITY C1A55 B BK � � VAUDATION
SQ.FT. NO.OF NO,OF CHEIX .
Ucense Number 51456� . lic,Cluss B SIZE SiORIES FAMILIES ONE
� VALWTIQ[iO
Gomractor TAE ANDEN GROUP pa}e 7I8IS� DESCRIPTION OF WORK NEw' S 7�Z S
Gara 2 — ADD '
❑I am ezempt under Sea �
ALTER
B.BP.C.for fhla rooson SLAB ONLY REPAIR = '�"'O I��S A
Date: USE OF DEMOI
EXISTING BLOG. #�.� • • • �
Siqnmure APPIICANT T��• fINAL G�
� OWNER•BUILDER DECLARATION PRINT TEiE..ANDEN GROUP. No, �TE '.`�//(i/�p I'• •��2 S
I hero6y affirm that I am axampt from the Contractor's License •7 Q 2 5=
�..taw for fhe following reaeon�Sec�ion 7031.5, Bueineas and ADORF55 Same HS Hbov FINAI ,,,��/J ' " c�
. �fesaions Coda): � �y /�!/��C*!"� .
� BUIIDING � O H.� 7`8�I
I, as owner of the praperty, or my smployees wilh A�DRE55
waqes as their iole eompensation,wil�do the work and ��'T� � � -�� '
thd strucwre le not Intended or offered for aale(Section � .. �
7041,Business ond Profeasiona Code). MOviNG TEL �
� I,as owner of fhe property,om exclusively mnfracting NTRACTOR NO. � i � ,
with Ilcensed coniractors to conatruct the pro�ecf(Sec- ADDRE55
tion 7044,Bueiness and Professlona Code). --
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTApROP.LINE WIDTFI
I hsreby offirm thai there is a construction Iending agency for FRONT
Ihe performance of the work far which thi:parmit is iesued p,L,
(See.3097,Civ.C.). . SIDE
v.�,
tender'a Name Citibank
LDMA Ref.M
$ P.C.Fee S Permi�Fee 6 3.7 5 '
Lender'sAddress 444 S. Flower. L.A.� 90071
� I certify that I have road this opplitation ond atate that the �esuance Fee IDMA P/C N
obove inform 'on is mrroc�.I agree to comply with all Counly � Invas+iqation Fee -
q ordinances State laws relo�ing�o building consiroc�ion, To+al Fee IDMA Perm.N
and her ihorize represanlolives of ihis CouMy to eMer
� upon t e ' ned properry for inspectio/np urpo/se�s.
� C�'C' Da � SEE REVERSE FOR EXPUNATORY LANGUAGE
Sigriqluro of Applicant or Agenl fe �
PtANS TO APPUCANT INSPECTCR'S NQTES � O6Vti��t t3LiIL,I�I H UL(:I.AHA 170\
_ I h-�aby�ff� �F.d I nr c _-iE:�t 4 i" �Cnrr .. .
To: � Rsturned . . . ilc•nie Lovr'tar the� inll �nq re;o-� . (Sec. 7���`.
ApProved - Iin.ainess nn 1 Yrnl��ssinns(;ndc:A n u ciiv nr r�>ursti�rrl�ieb
No. Date No. Dote - .. � � .. � rryuir��.a q pvrn�itYo cnn+fru�7,.elier,imr,rnrr.d<•�n.,li�h.
----- -� __---- — — . orr��pniranv.errudnrr,�ri rJ��iLvAsuui�,.r:.uCrr,rrAj,cirrs
. , � 7l r upplicunz/br u�h perneit tn Jilr Q sr,c'r:rd st.rtenrvnt
— _ ,.. � . — — thrstic�sG�en dJ s:u tt d yn is n. IN ( �
� �J . '. . - . .- .. .._.. tra��nr'el��en 1 i I(�/�pt. ))/<ni rn�� ��u t!S.�-
—_— — �----- ,t�,n �nnul�,/ta �,.n 3 /rt� r3�,«n �d r�„�,.�,�,n�
. . . . - - - , � _ �CndeJar'th�t l rcnz/�!1!e �J nnr a d tl r.hnsi-(,r fAc
� aUr,ked excmptinnFAnv vinletinn nf Sertion 'Oj�l.�h�.
. . . � ke9uired DateRseeiwd� . . untaQfli.unt/nrap��rn�it hf .�..then) l��axtt.r�.irrt
APProvols or Approved — pen�llv n�nnt m��rv ihun/rr�. Irundr.J d�11m�.a(CSOUJ J�
Ves No
. . . . . . . . . . I,�s owne�of rhe properfy.or my emplo�ees w�rh
Woiar GnrtlHm•z � � . • - wnges os�heir sole compe^�,onon.wJl de ihe work,and
� the slruc�ore ls nni inicnded or offere*d 4or salp(Sec 7(74Vj
Hcnith�eparrmant . __ - � � . . , . 6eesinrsxundPn�essinnsC:�d�:77eCnntr.e�tur'cLi�:ense
.. l.vee dnes not applv.ro un n o/prnperrv ioA<�(.ur(Js
Fire DeP�riment . . —"— nr imfrrui�as tbcrenn,and iebn Anes smr5 s��urk;I�r»r�arl/:
_ , _ tGrou,qh hrs nu•n�crnplqynes, prnriAcd tb�i� e'u.h u
Gradin9 . . . . . . . J�roremeats nre o�nt irt[�.nd / or a�/c ed J�or salr. IJ,
. . � . _. . .. . .. . . . bm<rner,tkre 5ai�dinX or i prr venoen�rc anld u•itGiu nne
Geolug�cal � � . ' � t'�ur nj�Mrr:p(etinn, tf,�e mm�er-huildrr i'il! Gure the
. .- - _.. . ..-- . hurdnn n//,+rurin�thnl be drd nu11>ieifd n mhrnre/nr
thi p pusa nJ ealr). �
�ae�v�«,R�we.Fi�en , '.
(Fenc�)ICa.iopyj - . �._ I,asonne�roft4;e��oprrty ame ... ,,lyce_ .c
Ilnq wnh licens d controcfor,•o c�nxh ct it e proie (Se<.
Soc<.lal 1 specl�oe . . . . . � . . . 7044 Oe srna�-snd Frnj<.sri nx !. ile� 'I'J�c Care! rt
l.o�c.?{MnsonrY7 IWPIdIngY . � ._ _ . .. . _ , . - 1,rce s f w�6aes n 7 s/pl�In-tt rner.f'prope t� 6�
hu�lds m irnproras tbrrcrn,�und uGn con(r�rcls%ir vaib
Lr,+pra�noae � _ _ . yn��jeets u•rt6 a mntra�'tnr/sJ lirvnsrd pnnrudnt to N e;
- � . Crin[rncfnr's 1 icense I,au�J. �
Porklog � � �� � � � ,__ Iumexe�npt+.inder5ec .6.&P.C.fo�in�s
reaso��
� - � . � . . . _,..
Da�e Ow.,er
ApprovaEs Dola Ins ector's Signcture : � � � -.� . INSi'ECTOR'S NOTES
_._._. _ (" —� .'__-__ .._.._.� � — ,-
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I`r�-$—� i-ck 8 Ya Cs; � . .
' .u.�i��i'a � . � .
Slnb I
f
Frome
� .._�._' '_ .
Fnerqy Ins�la�ion � ' � . �
o.h;Drywall- _"_ . . .. . . . .
i��
�'.mh--Exterior - ` - _ - —
�;—
I�'��use NnmEx3r_. . . . _ ._-„ . .. . � .
�Cor.eU&Postr.d
f�nol- . . . . . , '.
F,�fe�on Pront �
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