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HomeMy WebLinkAbout0757A ..,_ . WORKERS'COMPENSATION DECLARATION �� � - � - ' - " � '-�� .� , ._. .: -. . . . . . I hereby affirm that 1�have o certificote of�o�=e�„o se�F - �qPPLICATION FOR .BUIL�DI�NG P�RMIT �� � insure,oi a certificaie of Workers'Compensation Insurance, ' or a terfitied copy thereof(Sec.380D,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �3WC005-279—OOlf� Nationwide' 2/C Pollcy o. � � �� -Compa y -- � BUILDING � Cerrified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 598 Armltos P1aCe �. �Certified copy is�filed with ihe counry building inspeo- BUILDING . tf6n department.-' � ADDHESS oore 7/$/8� npPi��an+ THE ANDEN GROUP arv Diamond Bar ne 91765 �ocr,urv Diamond Bar ' CERTIFICATE OF EXEMPTION FROM WORKERS' - � � �- - - � -� NO.OF BLDGS. - � NE4RE5T � COMPENSATION INSURANCE � - � SiZEOF LOT NowoN�or ceoss sr.D�iamond Bar,-Blvd./Golden Springs (Thia 9ection riead nP>-be�complafed if fhe permit�s for one TRACT 42579�� e�ocK - �oT No. 19 � nnnP OOK���- �� PAGE� PARCEL hundred dollors(�I�O)orJess.) . . SE� � USEZONE MAF 1�7 2 I certi4y that.in the performance of fhe work{or which this OWNER - NO. _ NO. r ``�✓ � � � permit is issoed,I shall not employ any person in any manner .. P,O. Box.3329 ... sr�ani so�as to 6ecame s'ubjeci io the Workers'Compensotion laws. /+DDRE55 CONDITIONS V �., cirv Covina ziv 91722 � ,fICE TO APPLICANTA�.Pf I�af(er making-Ihis Ceriificate of ARCHITECT 0a - TE�� DISTRIC7 GRpUP TYPE FIRE PROCESSED BY �C Exemptionr'you should become sUbject to�fhe Wo�kers' � ENGINEER � NO. _ CONST. , ZONE Yy� � Compensation provisions of The Lobor Code;yoU musf fOrth- qDDRESS 3.�L�i N. Fir t Arcad a 1 � �O � u h`�' u�.t � • '�`,��P y with comply witb such provisions or lhis permit shall be 7EL � STATISTIG4tCIRS5IFICATION Avi. .CON�O.- x deemed revoked:,, - � �. � � CONTRACTOR TAE ANDEN GROUP No. . . (wmmenung wifh�CONTRACTORS DECLARATION � � � �--�- � � -- � �uC. C1A55 NO.�_DWELL.UNITS LICENSED I hereby affirm that 1 om licensed under pravisions of Chapter 9 ADDRe55 Same as .above No516560 ��R�P . . . . Professions Cade,a��ion 700D)of Dwision 3 af the Business and .. LIC. d my license re m full torce and effett. CITY CLAS �BK �-� � - �� VALIDATION 5�.FT. NO.OF NO.OF CHECK � ' ' LitenieNumber S1O$E�O ��� Class' B 51ZE L3�.�F STORIES 1 FAMILIES ]. ONE . . - . . VALUATION . . . TEIE ANDEN GROUP oescRirrioN oc woRK S in le Famil NEw Contractor Date A� S O�8 z� , . ��-' � � � �I am exemp�under Sec. � --� � '- �448 SF. . . ❑ �� � � � �'� ALTER 8.8P.C.for�rhis reason .. SLAB ONLY REPAIR ❑ s �� -- � - . � . =�D 7 5.7 A � Date: - E STNG BLDG. DEMOL ...._ .�� • � � Signature ,. . ...... . . -. � . APPIICANT � � TEL. FINAL � d •(�Q(}Q OWNER-BUILDER DECLARATION PR�M. THE ANDEN GRO . N0� pATE / 1"�'`G2+� . . ... .... . �I hereby affirm thet t am exempt trom.the Contwdor's License poDRE55 FINALD��''�" � • c e�Fi CI��J�Q c=.� �w for The following-reason(Section 7031.5, Business ond � �°essions Code): R tv BY �E 1 7—8 7 �� BUILDING � � �. . I, as owner of ihe property, or my employees with ADORESS ,i .. wages as their sole compensaiion,will do the work and � �- :�'..� � the structure is not intended or offered for sale(Section ��'��TY � � -� ' � - 7044,Business and Professions Code). � � � � - MOVING � � - � ��� � TE�� �" � , � ; \ � - �� � QI,as owner af fha property,om exdusively coNracting C�N7RACTOR . .. . . . NO. . . . . ' , .:.� ,V � '� " . . .. . . with licensed contractors to consiruct Ihe project(Sec- qDDRE55 � � fion 7044,Business and Professions Code1. , � � � �� - CONSTRUCTION LENDING AGENCY " � � SET�BACK Y�`Rp HW� T�TAPROP.LI�NE WIDiH � . , I hereby pffirm ihat ihere is a construction lending agency for FRONT ' � -Ihe performance of fhe wo�k for which this permit is issuad � -��P.L - � - ��" - - �� ��. (Sec.3097,Civ.C.). SiDE a _ _ P.�. � Lender's Name � Cit1b8n1C. . � � P.C.Fee S � Permil Fee �DMA Ref.$ � , � - lender'sAddrass 444 5. Flower.Z.A. 40071 , I certify thot I have road this application ond state thal ihe . . issuance Fee 1�•5� L�M�°�7/C M � .�� - . � above infarma' n is covecf.I agree to comply with all Counry invesiigation Fee � . .', ardinances State laws relating fo buildinq consnuction, Toml Fee 6$•�� L�Ma perm.M- i and here orize representa�ives of this Counry to enter �� o upon�h - ioned property for inspec�ion rposes. - , , , a _. O � _ � p SEE REVERSE FOR EXPLANATORY LAN6UAGE 0 � ... Signaf�re o PP icant or A9ent ... . ._. a . ..... .. . .. .. . .. . . . .... . . .. . . . ..... . �� PtANS TO APPLICANT INSPECTOR'S NOT'e3 � OW.NF.R-BUILDERDECLARATION - . I hereby affirm thal I am exempt from tbe Contractor's To: � � Ralumed��. . � � . . - license Law for� the following reoson. (Sec.7031.5) � Approved Bruiness and Professinns Code:Any city or cauxty whicb � No. Date < No. Dato' requirea aQermic to construct,alter,improo¢,demolisb, . . -or repair any slrsscture.�rior to its itseanc4 uLso�reguires �� . . � , . tbe o/�plic¢nt for ssc6 permit to file a sig'ned stademersC � � ' � � � that he is licens¢d pursuant ta tbe provisiont f the Can- � � trrtceor's License Inw(CSopter 9J(commencirg ruil5 Sec- ' - ��- �- ' � �-"�"' tion 7000f oJDivision 3 of the Bazaiaess and Projessions � . � ��- � � � Code/ortbatbeisexerxpttbereframandtfie�basisJortbe �. . _. . --:,` _ .�..:� . .. _ _ . ... . . - � � all¢g¢d¢xemption.Any vioktiox of Section 7031.5 by ' - � � � Requirod� Da}�R�tsiv�d att_yapplicantforapermitsubjectstbeapp[icnnttoacivil . -Approvol�� Yef No� ��Approvod , _ penalty of not more 6ban five hundred dollars.(8500J./:. � � � � - - ❑ I,as owner of fhe properfy,or my employees wi1F Water Certificate � � _ ,. _ __ . wages os their sole tompensation,will do�he work,ond � -� � ��� - � � �� , , . the strudure is not intended or offered#or sale(Sec.7044) Heohh Deporiment � .. . . . . . . .. . . Busixess and Professeons Code:Tba Contrpcior's License . . Law does not apply to as owrter oJ proyerty wha huilds Pire Department . . . . � � � � -� � - or improves thereon,and wbo does sach urork bimsel�" . _ , . . - � tbroagb 5is own emQloyees, provided tbat sr�cfi Grading � � psnvementr are�not-iniexded or offered Jor.sale.-I,� � - � . - — . �bowever,Ehe building�or i�nQrovement is sold wilbin one Geologicol. �� ' � - - - �� . - . � year of completion, tbe ownervbailder�wil! bave�the �� � � �� � - -� burden of prooing thai be did not build orimpivve far PedeslNon Pwleciian � � . . . . t5e purpose of ralaj: � .. . .. .. ,. . (Fence)(Canapy) � � � � � � - � � _ ❑ I,as owper of the propeny,am exclusively mnirar ting with licensed canlractors b consiroct Ihe'project(Sec. Spetiaf Inspection -��� � � - �� - .- . 7044)Business and PraJeasions Code: Tbe Corstrpctor's (Conc.)(Masonry)(Welding) � � . . __ Licertse I.aw does not¢pply to.an owner ofproferty who . "builds or smproves�tbereon,and who contracts for suc� Lot Droinage . . . - . , _. .. . . . ... projeces weth a cnnmoctor(sJ.lecensed purswant to tbe � ��Cnntractor's License LawJ. , Parkin . . . .. ... ... ....... . .. .. _. 9 � � ❑ I om exempt�nder Sec. ,8.8P.C.for this �. . .. .. .. . .. reason � Date ... . Owner .. . Approvals - Date In�peefor't Signatura� . . . . � .. . .. . _ .. � � . - � INSPEC70R'S NOTES Location— � � (Sethack 8 Yords) ��- -� � - � � Foondations - � - - � - - - . $lab �1 . � __ .. . � . . . , . � - , . Frame � . . . � . � , � � . � Energy Insulation � � .. .- . . . � ,. . . � � . . . �� . . � Lath/Drywall— � .. . .. . . . . . Interior - - �- � � � Lath-Ezterio� . . � . . � - � . . ... .. .....� .• House Num6er— . � � ' � � � � ' '� . .. ' . - �� ' ' • ... - � Correct 8 Posted � Final— .... . .. �. . . . _ . _ .. . . . . . . Enter on Front � � � t � .. . . . . . . . . . . . _ _ . .. _ . .� �,, .. . . . '4"tr: �_��r� �. . � 5 ti .