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HomeMy WebLinkAbout0767A , , „ . . . .. . . _ WORKERS COMPENSATION DECIARATION - ` ' ' - ' � �� . InsureboraacertifcatteofWorkesrtCompensation3lnsurane" � � � � � APPLICATION� FOR �BUILDING PERMIT� ��� � �,. � or o certified co y'thereof(Sec.3800 lab.C.) , � -� � �--� � - 73WC00��279-0016 I�atiox�aide 1/A COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑olicy.No: Company � � . Certifed copy is hereby fumished. FOR APPLICANT TO FILL IN qp REu 606 AYm3tos Place ��� Certified copy is filed with the counry building'inspec- � BUIWING �, tiondapartmenf.� ' � AD�RE55 606 Ar t P1 Date �����5�87 r,ppu�o�� THE ANDEN� GROUP. �� �in, � ➢iamond Bar Z�P 91�7�65� : ��111Y Diamond Bar� �. � � CERTIFICATE OF fXEMPTION FROM WORKERS' � �� NO.Of$LDGS. � NEAREST � � ,� - �� EOMPENSATION INSURANCE SIZE OF LOT NOW ON LOt caoss sT.Diamond �Bar BYVC7./Golden SpT1RgS (This section�nead not�be complefed if the permit�is for one � - - � � � ��- ASSESSOR � , � � hundred dollors($100)or less.) , TRAQ 2 @IOCK LOT NO. - Mqp gpOK PAGE PARCEL TEL. I�certify thm in the performonce of�rhe wo�k for which.this OWNEk " - NO. US�OI�E � /1�'��7t � Y /C. � �i permit is issued,I shall nol amploy ony person in any manner � SPECIAL - � � d so as to become subject to ihe Workers'Compensation laws. A�DRESS P.�. BOX 3s29� �a� NDITIONS V .� :' . � . � ' � CITY . _ ..ZIP .. . ... . ..... .. .. . . « �1� Appliconf�� ' - ARCHITECT OR TE�� DISTRiQ. . GROUP TYPE fIRE PROCESSE�BV O r ��ICE i0 APPLICANT: If, after making lhis-Certifim�e of ENGiNEER Dave Szany AIA No,445-4073 CONS� q �J emption; you-should become subjetl to �he Warkers' - � .W Compensation provisions of fhe Labor Code,you musf forfh- A�DRE55 .31�i N. First� Arcadia �100� � ��3 V N .. _ . ,N with comply wifh such provisions or this permit sball be -�- � � TE� deemed revoked. � � � - CONTRACTOR � NO. STATISTICAL C IFICATION APi. CONDO:�- �Z LICENSED CONTRACTORS DECLARATION � � - � � �- -- �iC. � aA55 NO.�DWELL.UNITS I hereby affirm that I am licensed�nder provisions of Chapter 9 aooRESS S 2.1RP. 35 above ,,,o,510560 (commencing wifh Setlioq700D)of�ivision 3 of Ihe Businass and .._. . . . . . ���, . ��R�P � � Profe55ion5,Code,and my license is in full force ond eHecf. SOYFf. NO.OF NO.OF CIA55 B HECK . BK' �' " VA��DAT10N : UcenseNum6er �51�56��� lic.Clas's �B SIZE STORIES � FAMILIES � ONE � . . � � . r �. . oescRivrioNOFwouK Single Eamily, New � -VAwATION Conr�ac�or THE ANllEN GROUPpate 7/8/87 App � s 7�809 ' �1 am exempt under Sec. � � - -�—�G8Y8 e - -418 SF , � � -- � . . . . AITER � s z p J G /A C.for ihis reason . � REPAIR - �� � �� � B.BP. . • • o • s . . .... . . _ - . -- Dafe: E S7�ING BLDG. DEMOL .._.... .� 1 ... .... ' - APPUCANT TEL. /���/� I '� •7 4.2 5 Signoture � ��- - � �-�� FINAL , OWNER-BUILDER DECLARATIDN vRiNT � NO. . OATE - � �� -� � � � � �-� � �_ -I heraby affirm that I am axempt from the Contrpdor's License - �. 1° " ° /�l.G:�cz., �rr�.av ior the following�reasoo.{Section 7031.5, Business and ADDRESS FINAL � ' 'essions Code): ..-.. ... . . ... .. . BY � � . � ��' � I•'�7 � I, os owner of the ro er y P Y BUILDING _ . , + p p ty, or m em lo ees with ADDRE55 - ' - .. � _ . . -wages as their aole compensarion,will da�he work and , -'� - -'�' � ihe slrucWre is not in�ended or offered for sale(Section �OU+�ITY - . -� 7044,Business and Profasslons Code). � ��� � - � MOVING � ��� -��-�TEL �� �� � � - � �',� � � ❑. . . COMRACiOR NO.. . .. . ...,... . . . .. , I,as owner of the property,om exclusively contmning ���� " `� ?.� �����- - with licensed contraciors to construct the projed(Seo- qooRE55 � ' � � � tion 7044,Busfness and Professions Code). . . � � .. REOUIRED. YARD �HWY T�T�SETBACK F . � .. .. ' -' �� "�CONSTRUCTION LEND�NG AGENCY - -- ' sei snGc PROP.LINE wioiii� � � . I hereby affirm that there is a construction lending agency for FRONT �1he performonce of the work for which ihis permit is issued V.L� -� � �-� ' -� �� � -�� (Sec.3097,Civ.C.). SIDE m _ Citibank �� < Lander's Name � .g' . ..— ..- . -. P.C.Fee S � � PermirFee. ...6 3.75 LOMA Ref.X �. . . - LendePsAddress 444 S. Flower. Z.A. 90071 ' � 1.cenify that I havesead this applicotion.and state that ihe .... . . . Is�uanceFee 1�•50- IDMA P/C M .. . �� � a above informat' is correct.1 agree to comply with all Couniy Iovesiigarion Fee . . . - g ordinances ta�e laws ralating to 6uilding construction, . � Tmal Fee -�4.2 rJ tDMA Perm.N � � � � � �� � u and her a � ize represanwtives of ihis Counry to enter _ � upon 1 -m ' roperty for inspection purposes. � : . . . , _ � Q �� .. a SEE RFYERSE FOR E7(�UNATORY LANGUAGE , � Signatvre of PPl imnt ar AgeM . _ '. pp� . ... . . . . ... . .. . . .._ . . ... . .. . . ._ .�� I PtANS TO APPLICANT INSPECTOR'S NO7E5 � �— OWNER-AUILDBR DECLARATION ; . _ , I hereby affirm that I am exempt from the Contractor's To: � Returned License Law for fhe following� reoson.'�5et. �031.B) � � � � � App���od Business and Professions Code:Any city or munty wbich No. Do}e �� Nb. Daf� - - ' � - � . - - , reguires a�permit to ronsiracf,alter,'iatJ�rovg,demolrsb, . _ . or repairany strudure,Qrior ro its issuanc¢,a[sn reqnires . , ' � , � - , . � 15e applicant jor sucb pernsit eo file�a signed st¢tem.ew4 tbal he is licensed pursuant to tbe provisions aJ tbe Coro- . - � ' , - , tractor's License La�u(Cbapter 9J(tommencing.witb Seo . . - tion 7000J of Division 3 of dhe Business and Professions � ��- � - � �- . _ �'� � � ' - .. ���CodeJ or tbat he is exempt tberejram aad llie basis for the alleged erempteon.Any violatiun of Section 7031.5 by _ Raquirod� '�� � . . - �� ' any applicaxt for a pernrit subjects the applicant to a civil Approvals .,Yas No Dal�R�qiwd ennit o not more tban iue bundred da7lars asool.: or Approved � P Y I J l 1 ' �� - - - � ❑ I,as owner of the propeny,or my employees with Water Certificme . � � . � � . � woges as Iheir sole compensation,will do ihe work,and �� ` - � �" � � "- � � ��`��� � � � � ' �� the shucwre is not intended or offe�ed for sale(Sec.7044J Heplth Department._ _.. . . . . _ . . � - . - - ' � � . - Busixess ard Professeons Cade:Tbe Contractor's Licease � Law does no!apQly to an owner ojproperty who builds Fire pepanment _.:. . . ' .._ � . .. . � � -� . � - or improves thereon,and wbo does such mork himre!'� � . � - � ' . . � - tbrough his pwn employees,�provided tbat such Grading � . Qr�venoents are hot iatended or offered for-sale. � ��� ` ,�;: - -�' Sowever,the buildeng or improvement is so7d utitbrn one Geologicat . - � � . �- - �-� � yenr af��comQletioa, the-oumerbuilder'will hove tbe � -� � . . burdea of proveng lbat be did not build or improve/or Pedast�ianProtection - � . .. � � , � � . ,. � . . ibeQssrfase�nfsaleJ. � ' . . (Fence)(Canopy) � � � �� �- � �- � � � � � -� ❑ I,asownerof the propeHy,em exclusively conlrac- ting with licensed contractors io construct the projec��(Sec, Special���nspection � � � � � - � 7044)Business and Pmfessions Code: The Coxtroctor's (Caac.)(Masanry)(Walding) �� � - . - Lirense Lau�does nat apply to aa owner of property u�hn �- � - - � -� � � ' . ---bazildr or improoes�tbereox;and wbo coxtratts fnr such Lot Drainoge .�- ,. � � �.. �.�. . . _� . . ... . Qr jects wieh a controcao�/liceiared pv.r.suant tn tbe - �� Coritra'etor's Liaense Law/. "� - �- -� � - _ Parking .. - . . . .. . .. . _. . . . .. .. . . . - ❑ I om ezempl under Sec ,8.8P.C.for this . reason � � . . .. � . Date -.� �...Owner �. .. Approvals Date Inapeefor's Stgnafura , . - . . . . .. . . . - . INSPEGTOR'S NOTES�.-. Location— �� � � (Setback 8 YardsJ �� . . Foundarions � - ' . � '� � Slab �� ��� � - Frame .. . . . � .. .. . . Energyinsulalion , . - . � � .. � . . - . . � � . .� . � Lath/Drywall— .. . . . . . . - . . . . . Interior .. ... . . . .. � Lalh—Ezterior ' ' � � . - . .. . . . .. . HouseNumber— � - ---��- - � � - � � �- � . -� �,- Correct 8 Posted � � � � � . Final-_ . . . . . . . . . . ._._. . . . . En�er on Front . . '.. � ��� . . . . _ . . . . � .. . ... w� . �. � . , � � . � ''J �.S.- ",. ,.. � ti . x ;r l