HomeMy WebLinkAbout1759A 1760A WORKERS'COMPENSATION DECLARATION � � �
I hereby affirm ,�o, I have o ceriificate of�o�g��<<0 9e�f qpp��CqTIOIV FOR BUILDI NG PERMIT �
. insure,or a certificate of Workars'Compensaiion Insurancc,
or certified co rhereof 1Sec.3800,�ab.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY
7�Wc005-2�9-0016 Nationwide 2/B
Po icy No. Company
� Certifiad copy is hereby furnishad. FOR APPLICANT TO FILL IN BUILDING
❑ ADDRESS � 604 Armitos Place
Certified copy is filed with 1he coonfy building inspeo- BUIIDING
tion deporimeni. ADDRESS 604 Atmitos Place
�}e 7-30-87 APPlican� T� �IN �UP aTr Diamond Bar 21P 91765 ��,Tv Diamond Bar
� CERTIFICAtE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. NFARFST
COMPENSATION INSURANCE � 5¢E OF�O1 Now oni�or ceoss sr. Diamond Bar Blvd & Golden Spring
(This section nead not be completed if ihe permit is for one TRqR 42579 BLOCK l0T NO. 21 ^�ESSOR
hundred dollars($100)or less.) MAF 900K VAGE PARCEL
��� U E ZONE �P
I certify that in the performanca of the work tor which ihis OWNER j� NO.9( — �_' �. 7_3y
permit is issued,I shall�ot employ any person in pny mannar ADDRE55 P•�• �X 3329 SPECIAL �
so as ta 6ecome subject Io the Workers'Compensatlon Laws. BvU�J CONDI71qV5 0
CITY �.'OVllld ZIP 91722 V
���•te Appliwnt � �'
ARCHITECT OR 'TEl
OTICE TO APPLICANT: If, ofter making�fhis Certificafe of NGMEER Dave Szany AIA No, 445-4073 DISTRIQ GROUP TYPE FIRE ESSEDBV O
`Ezamplion, you should become svb�ect to the Workera' CONST. ZON F-
Compensation pravlsions of the Labor Code,you must forth- AppRE� 314 N. First, Arcadia 91006 ,,� R 3 ,j�J � ��one W
with comply with such provisions or this permit sholl be LL'
deemed ravokad. tE�� STA7iSTiUI WSSiFICATION APT. CONDO. tA
CONTRACTOR THE ANDIN GROUP No. .�-�
UCENSED CONTRACTORS DECLARATIpN � ���. MSS N0. ��� DWELL.UNI75�_ Z
I hereby wffirm�hat I am licensed under provisions of Chop�er 9 qDORE55 AS dbOV2 � 510560
(commencing with Section 7000)of Division 3 of the Business and . t��. SE`NER MAP
Professions Code,ond my license is in full force ond effect. GI7Y CIASS B VALIDATION
510560 B 5Q ��1314 NO oF 1 No oF 1 CHECK BK. vc.
License Number Lia Class SIZE 570RIE5 FAMIlIES ONE
THE ANDEN GR(JUP �J-3O�H7 DESCRIPTIONOFWORK S1S1 le famil NEW VALUATION
comracror ome s 6 8,2 0� . ='1 7 a 4 A
ADD
❑I am exempt undar Sec. Ci3L'd e 448 SF 7 0 • • •2�
AITER
B.&P.C.for fhis raoson REPAIR s � •�3�8 U,
Dote: u5E OF DEMOL
EXISTING BLDG. �� --c 2
Signature APPLICANT TEL. FINAL n `:='J:,u�F o
OWNER-BUILDER DECLARATION PRiM THE ANDIN GROUP NO. DATE 9 ���� c 9.1 6-8 7
� I hereby affirm that I am exempl from the Contractar'a License AS a�OV2 ����/
�ow for the following reason(Section 7D31.5, Business and /+DDRESS FINAL Gi��i"�
'nfessions Code): p 6y
'7 BUIl01NG .
�_� 1, as owner of tha property, or my employees with ADDRE55
wages as their sole compensation,will do the work and
the structure is not intended or offered for sala(Sec�ion ��+��T� �
7044,Business and Professions Code). MOVING TEI.
� I,as owner of fhe property,am exdutively conlracting CONTRACTOR NO. --�� 7�Q A
with licensed coMractors to construct the pro�ec�(Sec ADDRESS i��� • • • ° • �
tion 7044,Business ond Professions Code). �
CONSTRUCTION IENDING AGENCY REOUIRE� yqRD HWY TOTAlS TBA
SET BACK PROP.LINE WIDTH . � °�.�7 C•O Q
I hereby affirm iha�there is a construction lending agency for FRpryi
�he performance of�he work for which this permit is issued P.�. - o ,?.%:�,�r'�
(Sac.3097,Civ.C.). SIDE
Lendar's Name
Citibank P� D 9.1 6—8 7
444 S. Flower, L.A. 90071 P.C.Fees 233.84 r„m;,Fe, 361.50 io"�°'R°t.w
Lender's Address '
I certify Ihot 1 have read this oppliwtion and stafe thpt the luuance Fee �-O�.SO. � IDMA P!C k
above informetion' torract.I agree to wmply with all County tnvestiqation Fee
'7 ordinan[es on e laws reloting to building constructian, iotal Fea 3�Z.�OO IDMA Perm.N
ond heraby t ize representofives of Ihis Counly to enter
� upon the roperty for inspection-� .
o SEE RlVERSE fOR E](PLANATORY LAN6UA6E
Signature o�A mnt or Aganl �ate
PLANS T6 APPtICANT INSPECTOR'S NOTES � � (.ri1'h1�1!•RI�ILUI H 1)1:(:1.ANA I ION
. I V..ebY off�m thai I a c -.��pr f � -..tc;:'s
To: Rafwned . - .. � . � L<-rs= Lo�« 4ur ��.er'`�Ilc �u�g r, i�c��70?9S1
APPruvad � - 13usrness unr!Pro/ussians Cr�dr:Anp cr(i�n .nuntt'u�/�i�b
No. Dafe No. Qate� � � � rcyuirrs u/�e�rnirl�l��ron.itruc6 ultrr,i,rrp�r,rr.d��m�,li,l�.
___.._,._____.` ......_. __.... � .
�w..� --- � -- „ r u , 1 a r � r� r �
- . � , .. . - i/ ��p! �t! f��� r r J! c d r e �
. � -..-�-.-----. — . �, tl�at!:e !e�rn�d J ur � t t il.pr, � . /�l (
� �" . .. . . . . .tion 00(
. ' � tr�/i l.r rn 1 au/C! p1 ))/ n nl �rtl.S,:
-' - --- - . ? !J r�lln:surn 3 r�i tEe�l3usuu.cc�nJ I r��/e��iunc
, �-. � �— . .. . . .. '. . . � .. .... �� . (:uJr/ar th�t l c�'.c exempt tberefrnm�and!be ha.vis/rr Ibe
-- - - alle,yed exemptinn,dnv�.iral�etenn nf.Sertrnv ,'.113L5 hy
� .. . Required Data Reeeiwd . . . unv appli.:nn[fura prrnril xuhjecfs flrc aprlicxent tn,e.�iri!
Approval� or Approwd - ... .. peq kv r.J nni mnrr fban/ �:�lrandr��J JoUnr�(�+S1lOJ./:
Yac No .� - � - , � �
_____._.._,__ . _-�.�--�. .. . . ... I,as owner ot rha p�o[erty,or my e nFIoY ., w�.rL
s'aq3�Ce.ri�{if:�re •. , . � _ f� - - - . _ _ - . , wc yes as ihe� sole co p. �t oc,w II d�the a. k,and
� . _ ihe vrucw�e.�s .r„iended u offe�ed fo�sul?(5�c.70aa)
�Health Depar�mer.t... . � � .. . - .. . . Ursine��spnJPrn/eca�iun�(' !� ,ILo•Cunfruchirsl�e�nae
� .. . !, u d n[ p[rl�7 an n J( h� h J� l !ds
'Firc Dep<�rtment � -- . . . - �� f r � c t/ �. attd u 1 ! _�s 1 n �<u r.1(,--
.. . .. . � flr uSb {is �ua c�pli� ��)r.n! 1 tl t x ! i
Gm��.� . . . _ , . . �. Pmoernents are nnt �ntenJnd or ��/J�.ed !nr eulc. //,"
. - . � _. . - . . . hnever�er,tbc haifdin,r or un),rovement is��uld�rslbin nne
Geolqylca� . � � 9�ar n(�complctinn, !be owner-buifder anilJ hare the
_� . . burAen oJ frur�r+�,�IGu!br did no[hu�ild nr irnproae.jor
. � � � t5e•purposar nJsalrl. .
PeF.i�e�rlun Protacii«, � � � �L as owner of the �o er1� m e ��J��v.�el qe*+4rac�
�F.nc�r)lCnnoPY) . . . � . . .. p' p Y,a Y
_ — ti�q wilh licensed co��IrUctors to consir�cr Ihe pro�er.t�Sec.
• Speciol inspec�io�,. . . ' . . 70dn)F)usrnn.ax and Prnjecsrnxs Cude: 7'1 e Canfra��tor:e
fCe»c.l(Mason.y)(Weldin9l - , .. . Li<'en.ce I.ui��duer nnt upp(p tn an na-�ner i f prnpn�tti'u�Ln
. . . - . hu7ds nr i�rnprurrs 7lcmnn,a+�d arl�n�unMads Jn.s+uh
� prnjects udth a co�ntracLnr(.tf.live+:.vrd.pnrs�ixt �0 1Gr
Lot Dralnoge . � � ' -� � - .
Cnntrn�tnr:c I.ictnse l,aar/. .
Pa�kicg - -� �.. I uen�xempt undar Sec. ,B.BP.C.fo�161s
roosen � �.�
� � Dn1e Qwr.er
Appravnls Daie InspeeTor's Signature � � � � . .
� IhiSPECTOR'S NOTES
l.ncn+io n-- ��f,�/
(Sal6ack&Yards) � � � �C� f��7. �'/�'jG �
Fo�ndatiens � � II � �7�� � �
Slnb � ~
Fror�e �t � J�� �,r�,� . . ..
6 ' 'pr.�
'Enenrgy Insufa+ion ��Q �� �//,ryC - � �- �� � ..
_�._��/
i.n,t„o��waii.- Il �7 S'7 Q�.�1�,
�orc�rlo.
io,f,-ex�e,�� /p:.3 �'7 --�"�j � � ---
Ha�.i�NurnE>e�.- . . . . . , ... � . . . .
Co��ecr R Posv:ed
Pln. � .. . .. .
Enr ,n�F�Crd � . . .
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