HomeMy WebLinkAbout0778A WORKERS'COMPENSATION DECIARATION �
I here6y oHirm thai I have a cer�ificate ot tonsent to=e�t APPLf��I�TION FOR BUILDING PERMIT
insure,oi a cert�fico�e of Workers'Compensation Insurance,
or a ce.r�f�ed copy thereof(Sea 3800,�ob.C.) COUNTY OF LOS ANGELES BUIIOiNG AND SAFETY
Pai��Y�C005-279—O�p 6��y Nationwide 1/A
� cenif�ed coPy�s hereby f�rn�ahed. FOR APPLICANT TO FILL W nooRess 599 Armitos Plaee
� Ce�tifiad copy is filed with the county building inspea BUILDING 599 Armitos Place _
lion deportment. AODRE55
oa+e 7�8�$� Applimnt THE ANDEN GROUP �iT� Diamond Bar _ ZiP 91765 ���TY Diamond Bar
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLOGS. NFAREST
COMPENSATION INSURANCE SiZE OF LO7 NOW ON i0i cRoss sr.Diamond�Bar �Slvd�./Golden Springs
(This section need not be complefed if tha permit is for One TRACT BLOCK �p7 Np, �`ESSOR
hundred dollars(Z100)or less.� 1�L1P BOOK VAGE VARCEL
1EL. US O E NWP
own�a THE ANDEN GP.OUP ivo.967-9541
I certify tho��in Ihe performance of the work for which this �� NO. � "'3� �
permit ia issued,I aholl nof employ any person in any manne� qD�RESS P•p•�B ox 3329 SPECIAL �
so os lo become subje[t to the Workari Compansafion Laws. �O V CONDITIONS
,^ aTr Covina zia 91722 ' U
Te Appliconr Q,'
ARCHRECT OR TE�. DISTRICT GROUP TYPE FIRE P SSED BY O
.OTICE 70 APPLICANT: If, dr,B, making�this camFl�are of NGINEER Dave Szan AIA.� � n,o.445-4073 �fy�
Exemption, you ahoold become sobject �o the Workars' - �J ����-- � �/ �"'
Compensation provisions of the Labor Code,you must forth- ppDRE55 ], � /v ,`3 � �' W
wlth comply with such provislons or this permit sholl be TE� Q•
deemed ravoked. GONTRACTOR T�' .�DF+N C*R�� Np STATISTICAL C ICA71pN APT. ONDO. (p
LICENSED CONTRACTORS DE0.ARATION - ���, CLA55 NO. DWELL.UNiTS z
I hereby affirm iha�I am licensed under provisiona of Chap�er 9 ADDRE55 Same as�above - No. -510560 ��R�P
(commenting with Section 7000)of Division 3 of ihe Business and LIC.
Professions Code,and my license is in full force and effect. CITY CLP.55 VALIDATION
50.FT. NO.OF N0.OF GHEIX BK� �''
License Number 510560 ��� ��ags B SIZE STORIES � FAMILIES ONE �
� VALUATION
so�o-o�fo. THE ANDEN GRDUPpa�e 7/8/87 DESCRIPTIONOFWORK Sin le Famil N�
ADO ; 7�809
�I cm exempl under Set. � — 1.$. �'.
SLAB ONLY AiTER � , �Q��.S A
6.8P.C.for ihis reason RE7AIR � s
#• . • • • �.
Date: � ��� DEMOL
EXISTING BLD6. ❑
SignoWre AGVLICAN7 7EL FINAL � o �`7 4'2 5
OWNER-BUILDER DECLARATION vRIM THE�ANDEN' GROUP NO. OATE �/�v`� x
I hereby affirm that I am ezempt from Ihe Con�ractar's License • � •7�1.2 5 0
�Low for the following reasoa(Sectlon 7031.5, Business and aooaess � Same flS -abOVe �� FINAL
. jfessions Code): By �P � �`$7
� eUILDING , �
I, as owner of�Iha property, or my employees witb ADDRE55 L �
wages as their wle compensation,wiil do ihe work ond , ... . � � �
�he atrocfore is not Intended or offered for sole($edion ����TY .
7044,Businass and Professions Code). NAVWG TEL. -
� I,as awner of the property,pm exclusively toNrocting ONTRAC70R NO. _ �
wilh licenaed contractors ta consfrucf Ihe prole[f(Sec- ADDRE55 � '
tion 70d4,Buainess ond Professions Code). � ' � �
CONSTRUCiION LENDING AGENCY SE7�BACK YARD HWY TOT PROP lME WIDTH
I hereby affirm�hat there ia a conatruction lending agency for cRONT
the performance of the work for which this permit ia isavsd a.�. �
($e[.3097,Civ.C.)• SIDE
P.L.
Lender's Name Clt3bank -
$ 444 S. Flower, L.A. 90071 P-C.Fse S Parmlr Fee 63.75 ��Ref.M
Lendar's Address ,
� I certify tho�I hove raad this opplication and atote that Ihe .. iuuanca f�el O•5 O LDMA P/C i1
above informa n is eorrxt.I agree to comply wHh all Counfy Invese�gation Fee
ordinances d Stute lows relating to bullding cOnstruction, Totol Fe� 7Q.2 5 LDMA Perm.N
and here a or{ze reprosentativee of this CouMy to eMer
� upon th a -m 'oned.propery for Inapection urposes,
m fEE REVERSE FOR EJ(rIANATORV LANGUAGE
� Slgnofuro of plican�or Aqenr re
PLANS TO APPLICANT INSPECTOR'S NOTES � O�l`I\f R BI�ILUI H i)P:('.I.AH 3 PIU\
�. I h ehy off� I�:�t nm ..� F. tr � Cnn � ��.
� - Llc.'.r Law� f �r,e Fol �.� .<. IO'li 5i
To: RWarned � �
- APProved -- I3resirccsn'nndPr�r/��.sciunsCodc:AnvciaT�� ,��urs7vu�bicL
No. Dafe No. D¢fe � � . . r«�gur �<afrern:i6lnro.r�vtfu�Y.dl7rr,.ernprur���,�demufiaG,
re
_��-._�.__._ . _._._.__.-._ '.__.�..._. r�a rrp�ir�nv clru<furc.Pr.. .t 'tc ic.c�. .,-.uL,nrr�quir�-�
i
- , ' . - � rGc a/,p&cuor/n.curh p��rnne rn(l1��a s;ene,(.sr.�eem�•nt
..:-_�_--_ �._ �_...—. � .-.-. - .. . [bat Gc i.<licens��Jpurs,e.�nt rr�tbrpr��idae�,rss,�l Ihr Con-
. - _ . .. . � � irn<rr�n'.a 7.i���nae l.a�rlCb.aprer!JJl<�o,nmrndn.4 u�iah5,.�o
'—'-�--- .. . � Jir�n?Ui)b/nf.Uiz�isiqn i nl tbe Nu�aucs.c,end.PrnJrai��ns
�� . . . .. ... . . . -, G l�l,�rlb��t! .�excn�pttl�re/r.>re�nlN� kmL��(�.rrle
----- — a/!,Qed exen�pti in An v+.i�l atr�n nJ S� r na 'P�3 7.5 br
.� . � i" Required DetaReeeired . . .. autiupplir<mt(urnpern�rtauhp�ea.fhvapp!icrrhtt.scii�il
APProvala — -Ves N°...� arApprov.ed -. - . . Penit��l,osomn".Tol`heJF`��h'Yn�nld/l�ln(S5G(1J,'�,.,
� . E h i�.o � . - - - . . wag s s�hel o�e .. p . o .a 1 c+ h_: �- a
._ _�, _� � . .. � �k si <ture�s �� ,e ded� offe eo o s �. (5� 7(7 )
He�l��C ep en* � � � . _ I)+as nss�unJ Pr ksaror�s f l� ll i C t s� r I s<
l.au J .v n [opph to ure �ncr J pr p< �t r!-, hurlds
�.e Depor.rn_�. _ or i �f s therr„n,�nd I J ..s l ,F/.r ./I ^
_ . , 1hr u,�! hia nan erePlnl<i+. f.ror�led ib✓t.sur(i r�.
-r��j,�� . prne�nments urr not inrenJned n u//c.ed/or svla If.
_____ . . . . _ � - .� ' . (ioirre�er,the bn.iJdinX or inipror�crnent rx�old a�rihrn nne
Geologicoi , . . � . ycur j completiurs, the tn r•heilder vi!!hrtre the
�Gu dr, !prnnrnq rha�!, !"d n���Guifd nr,orpro�e!�*
Peel�uk on ProFeci�� -_ . .. � . th.r rf s�-of ialeJ. .
rFence)iConppyj . � � � �_� I,as owner of the propery,am exclus���ely coni�nc-
ting w�th licensed<o��froGo�s ta construd<Me p�oiec�Sec.
�ps+unl inspcction - . . - . . . . 70441 f3usiness anJ Prn(essinn.��C�ude� 7'!rc Cnnlra�tor'.s
n�!(Mosonr�)(Weldin6l � � , � � �_ - ._ � . .._ . ,_ lrren e Ln�o dnrs nnt upplv tn an�nu�ncr uJprnj,erry a•bn
� - � hailds nr�imyrne�ccs tl erenn,aud wbn rnrstr�.ts�nr sacb
Lor D�o�no9e . � . . . . p.� e i�.drb n:ovrra<our(aj IGr,�scJ�.�:��r;uant rr, iGF
-G r rd��l.ice»5r Lu�<).
iParki•�.9 . .. . . �.1 I am exempf under Se<. .B.BP.C.kor fh�s
� . . YC�50� . . .�
� ' �(]�C _ �wr..
Approvalz �atu laspacior's Signafure � . ' . �' _. _ - _
�J_ _ _ _ ' � � INSPECTOR'S NOTES � -
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'�SerFack E Yords} 9`� g � � � -
Pound•niuns �1, , _ . . . . ... '_
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