HomeMy WebLinkAbout1723A 1724A . WORKERS'COMPENSATION DECLARATION � �-7
�iPI�LICATION FOR BUILDING PERMIT `' �
I hereby affirm thot I hove a cerrificote of consent to self u
. insure,or a certifica�e of Workers'Compensa�ion Insurance.
ors cer�ifiad cop �hereof Sec.3800,Lab.C.) �
73Wc005-27�9-001 Natioriwide 3/C COUNTY OF LOS ANGELES BUILDING AND SAFETY
PalicyNo. Company
� Cerrified copy is he�eby furnished. fOR APPLICANT TO FILI IN BUILDING
ADORESS
� Certified topy is filed wi�h the county building inspec- BUIIDING
1io�deparimeni. ADDRE55 6�0 ArI171YA5 Place
Dote 7-30-87 APPlicanl 7'� �'�IN GROUP ciTv DiBlitorid Bar Z1P 91765 ��,�iTY
CERTIFICAiE OF EXEMPTION FROM WORKERS' NO.Oe Bt�GS. rIFARESt
COMPENSATION INSURANCE SIZE OF t07 NOW ON LO7 caoss sr. Diamond Bar Blvd & Golden Spring
(This sec�ion need not be completed if the permit is for one � TRA� 42579 BiOCK � LOi NO. 20 �ESSOR
hundred dollors($100Z or less.� �P�� PAGE PARCEL
TEL. U E ZONE �/ �
I carfify thaf�in Ihe performance of the work for which fhis OWNER NO. — ��' NO. �� /-3`�9
permil is issued,1 ahall not employ any perwn in any manner qDDRESS P•Q• �x 3329 B��Q OENDITIONS �
sa as�o become subject to the Workers'Compensotion lawe. �
arr Covina zia 91722 �
r`ate Appiicant (Y
JOTICE TO APPLICANT: If, offer making�this Certificate of ARGNITECTOR TE�� DISTRICT GROUP 7vPE FIRE PROCESSED BV O
ENGINEER Dave SZdTl AIA No. 445-4073
Exemption, you ahould became svhject to the Worke.s' � (� �ST� � V
Compensalian provisions of the La6or Code,you must forth• qDDRE55 314 N. H'1TSt Areadia 91006 �� K�'� ,�'I -
with comply with�sach provisions or this permit shall be � N y.Y�— 4, ry Q W
deemedravoked. TE�� STATISTICAICLAS5IFICATION +� APT. CONDO. Z
CONTRACTON NO.
UCENSED CONTRACTORS DECIARATION AS dI�OVO °C��510560 na55 n10. b� DWEtL.UNiTS
I hereby offirm Ihoi I am licanxd under provisions of Chopter 9 AODRE55 Np,
(commencing with Section 7000)of Divisio�3 of the Business and 4�� SEWER MAP
Professions Code,ond my license is in full force ond effect. CIN CLASS B gK � VALIDA710N
510560 g 5° `r 1409 NO OF Np,pF 1 CHECK
license Number Lic.Class SIZE STORIES 1 FAMItIES ONE
Tf� ANDIN GROUP 7�30-87 DESCRIPTIONOF WORK .Slll le famil NEW VALUATION
Confractor Dafe ADp ❑ f �2�$QQ . �
�I um exempr vndar Sec. Gc3L'cl e 462 SF L� �2 3 p
ALTER
B.&P.C.for ihis reason REPAIR =
Date: USE Of OEMOL #s • • •2�
. EXISTING BLOG.
Signature APPIICANT TEI. � •2�U.�r`
FINAL
OWNER-BUILOER DECLP.RATION PRINT NO. OATE I j't' ��
I hereby offirm thot I am exempt from fhe Coniractar's License j{5 d)JOVe � $���t�'`,���
law for the following reasan(Saction 7031.5, Business and ADDRE55 FINAL
/�""'rofessions Code); E � by 0 9.1 6-8 7
� BUILDING
I, as owner of ihe property, or my employees wilh ADDRE55
wages os iheir sole compensplion,will do ihe work and L�L TY �
fhe siruclure is not intended or offered for wle(5ection
7044,Business and Professions Code). MOVING � tEL. . .
� I,os owner of the propeny,om exdosively conlracting CONTRACTOR No. �:1 7 2.4 A
wirh licensed controctoro to consirud the prajad(Sec- qooke55 �
tion 7044,Business and ProFessions CodeJ. �f� � . c • �
CONSTRURION LENDiNG AGENCY SEQSACK VARD Nwv T�TApROP.LINE wiorH
I hereby offirm that there is a construction lending ogency for pgp� 1 'v 9�,Q�
ihe performance of�he work for which ihis permi�is iesued v.l. �G Q G C��
(Sec.309J,Civ.C.). SIDE �
L`1t7bdI1�C P.l.
lander i Name 0 9,� 6^P��
IDMA Ref.M
3 444 S. Flvaer, L.A. 90071 v.c.�es 24k.55 vs�n+uFea 379'.50 '
Lender's Address
I certify thm I have read this opplication and state that the - issuance F« 10-.�50. iorrw Pic M
above informotio "s corred.1 agrae ta tomply with oll Counly Investigation Fee
ordinances a ote lows relafing to building construtllon, Totol Fsa 3 .Q-..Q IDMq Perm.M
' and haraby u rize representatives of this Co�nty to enter
5 upon the e ' �ed property for Inspection purposes. L DMA �—� $�rJ.O O - � $3 S�.��
_ `' bEE IIEVERSE FOR EXPLANATORY MNGUAGE
Sigrwrure of plieane or Agenr po�
PLANS TO APPLICANT IP:SPECTOR'S ND7E5 � UWhI H-RU]LUkR lllICI.AR+.�PtOti ,
. , . - -- . I hrie.by aff.m tha'I a .�,p�'.i.� ihe C.-nnrrw:kr's
To: Relaroed � � , . ,� . License Law . r ihe followmy� r..nson� lSec. 7pJ1 5j
ApFravad -- ' — Ausir�rssanrlF'rofrsxiunxCndc:Anv<itt'nr:oantv�r�(�i�b
No. Daf¢ No. � DaTo �. � , reyuirrs u prrndt lo rnnslruct,dJtdr,irn�n�re,dame�lic,h,
.—_.__.____.... —.— .—_-----_ ur r��prurunr-:vtru<aurc.pruir tn at.�.caeam�.�lsn rryuirr���
--... ..._�_�__ ._— --"-
. . . r/,xc uppli<,unt lur sr.ch f�vrmit ta fifo a si,qned sr,:rcrnvn�
�.�.�.—_._. � _ __�_:___ .___ ��.�_�_.—..�..- d�uf bc ix licensrd pucsurnt tn tfrr prurrsions nl!hr Cun-
� ... ea,�r.,,�t�r.r�r,�.,���r.u«�rG,�pr�•.�l�.,,,,,n,��n���,�,�,��;r,,s�:�:
---- — — . dirin 7001J1 r/Uia�isina 9 0/Ibr Busim<rse��nd Prnfr.uinns
-- . .. . - : . . . � . .�.�C„dc/.�.r[wr!<-r����.r��.upr rb�.�-/.�>,,,u d t,>��h�„r.,�r„r re,�
-- �lle,qrd ex<�mrtinn..4nv�'iolntina rrJSertinn'H31.5 hti�
. . � Requirad�. � � . . . . anvapplerantlnrupern�its:�blrtttstbeappli�nntrou�:ii�i!
A ovols Uafe Ratvived. ��
PP� or Approved panulty�o%�rint nrnrc thun/icc Lundred Jullan/�5(IU)J:
�
Ves No . . �� �
��,_,�� :�,,�.,- �,� -_- - � � � �. I,as own�r o�fhe proF,lmrty,or my employeF�s wnh
,PJme < .�I�c:a�e _—� _'_ �- ... ). ',. . . .. - . . . woges as the� ,�le campensot on,w II d Yee wn�'u,and
fhe strucwre is o+���tended�or offartn!o s s'e(See 7644)
H*oii D.p�t iem � .�. = . . . ... . .$ sr ss ndP �fa� >ns l d. 1!�( nt.�v sl �. se
.��_ .�� . Luu<I �. nul app(v ln un i a (h p h i E h lJa
R�e Cepanmen� ��..� —._. . � � � or np �v th.r n.und ! d _.v l u rh fin� ljv—
, . d�riu,�h Gi.e nrn crnpl���c�.s, prnroAaJ tbul su b r.
Grad ng . . . .. - .. � �. � . , .. ./�mtemenfs urn nof inlendeJ rr r/jrred/r+r xuCn. IJ.
_ � . . . . . � � - .. J.on eoer,t{rn bxiGfin,q or imprnnement zs enld�rr�hrn nne
Geolo�icol . ��e¢r n(�com/rlrlinn, !ba ou�nor-huildar�u�i(! horr the
�� _ -. . _ .. . . . : . burden nf prnrin�lhr+t!�e did n.�!breild nr rmprm c jor
Pedes/r�ori RWecnon � � . , � . . . . tl�e pur/iosa n/snlr7. . �. .
iF>nce)(ConopY) . � - . - �_) �..I.pso.vncro4t4�nproperty,ameri:l�isrverlycon«ac�
�ring w�ih lice�sed co�itroc�ors ap constr�cr�he proieu r5?c.
Sp�col Inspcctlon � - - . - . 7p4a1 fi¢einvsc anJ Prn/�s i.v Cr�d� 1!r Cnntra��tnrS�
K.onr.�'MasonryJ(Welding) _ _ _ . . , . f.mexce l,a�rdver not�ppl�t �n ou�n�.o f prnperty uGn
. . �hur7ds n rn�rur�s 1Le.reon,an.!u�dm.�n�racta�nr sxrb
,ni Dromage= ' - . � . . . . /� 3eeEx�udth 4 enntract Y/cJ li��i,nsed pim��uant !n tle
. � - C'rineractor's l,icense Lai<�/..
pc:rk��ng � � .._. I um exempt undmr Sec. .B.ftP.C.fcr rh�s
. .renson . . _� _ �
f7nie � . . .. Owner _.
i Appravafs Dats Inspec#ais5ignature � �� ' , .
� . � � � INSP6CTOR'S NO7E5
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