HomeMy WebLinkAbout1739A 1740A WORKERS'COMPENSATION DECIARATION � ' �
I hereby affirm rhoi 1 ha�e o�a,,,f,�ofe of�a�5e�„o,e�f APPLICATION FOR BUILDING PERMIT �
, insure,or a cer�ificme of Workers'Compensotion Insurance,
o cert'fie c thar of LSec.3800,La6.C.) �
�J�WcbO —�9-0016 Nationwide 1/A COUNTY OF l05 ANGELES BUILDING AND SAFETY
PoliGy No. Company
� Certifed copy rs hereby furnished. FOR APPLICANT TO FILI IN Bui�o�Nc�
ADDRESS
� Certified copy is filed with ihe cou�fy buildin9 inspec- BUILDING
tion department. ADDRE55 606 Axmitos PlaCe
Da�e 7-30-87 APPlican� TI'� �DIN GROUP C11V DiamOnd B3L' Z1P 91765 ia,e,�irv
CERTIFICATE OF EXEMPTION PROM WORKERS' NO.OF BtDGS. NEAREST
COMPENSATION INSURANCE SiZE OF lOT NOW ON LOT cRoss sr. Diamond Bar Blvd & Golden Spring
(This sedion need not 6e mmpleted if the permit is for one 7eaCt 42579 g�p�K LOt NO. 22 ASSESSOR
hundred dollars($100)or less.) N.47800K PAGE PARCEL
TE�' USE ZONE 1�P �2
I certify�hot�in�he performance af the work for which�his OWNER NO. — ��' NO. � —.l�Q
parmit is isaued,I sholl nof employ any person in ony manner qDDRE55 P•�• �X 3329 SPECIAt �
so os lo become subject 10 Ihe Worken'Compensation Laws. QOd GONDITIONS �
qTY COV1Tld ZiP 91�2 �
('"tite Applicont �
ARCHRECT OR TEL
JTICE TO APPLICANT: If, after making this Cerfificote of ENGINEER Dave .SZdTl AIA No. 445-4073 DISTRIQ GROUP C PE�T. ZONE ��SSED BY Q
�E:emption, yau should become au6ject�lo Ihe Workers' n ^� U
Compensotion provisions of ihe Lobor Code,you must forth- qDDRESS 314 N. First, Arcadia 91006 �O `\"J �N rna` A�s W
with tomply with such provisions or ihis permit shall be . � 4 d
deemed revoked. TE�� SrATISTICAI C1A551FICA710N AP7. CON00. (p
CONTRACTOR NO. � Z
IICENSED CONTRACTORS DECLARATION ���. CLASS NO. � �Q DWEIL.UNITS�
I hereby affirm that I om licensed under provisions of Chapter 9 aDORe55 AS above � No 510560
(commencing with Section 7000)of Division 3 of the 8usiness and ��� SEWER MAP
Professions Code,and my license is in full force and effetl. CITY CLA55 B BK � YALIDATION
510560 B 5°.FT.1535 NO OF NO.OF CHECK
license Numbe� Lic.Closs SIZE STORIES 2 FAMILIES 1 ONE �
VALUATION
co�nac�or T� �IN ���pore �-30—$� DESGRIPTION OF WORK Sin le fdmi.l po Q s 7$,0 9 0
�I om axempt under Sac. C'ard e �18 $F ALTER � ,
8.8P.C.for fhis reason REPnIR s
�afe: USE OF oEMo�� 1 7 3,9 A
EXISTING BLDG. L
Slgnot�ra APPLICANT TEI. FINAL
OWNER-BUIL�ER DECLARAT�ON PRiM NO. DATE � ��/� #• • • •��
I heroby affirm that I am exempt from the Conhactar's license j{S d}JOVO
Law for fhe following reason(Section 7031.5, Businass ond ADDRESS FlNAI �j� � •�6 a,b�
f"`•ofessions Code): � �By
� � BUILDING • c�(�(�.(�1 �
I, as owne�04�he property, or my employees with nDDRe55
wages as their sole compensation,wil I do Ihe work ond LOCALITY ' �9�� 6"8 7
the structure ia not intended or offered for sale(Section
7044,Business and Profesaions Code). MOVING TEL.
� I,as owner of the proparty,om exclusively coMracting CON7RACTOR NO.
wi�h licensed confroctors lo constr�cl Ihe project(Sac- qDDRESS
tion 7044,Business and Professions Code).
CONSTRUCTION IENDING AGENCV SEQBACK �ARD Hwv TOTApRpP.�tINE wiDiii
I hereby affirm that there Is a construttion lending ogency for FRON7 �� ��'�A
the performonce of tbe work for which this permit is issued P.L #• • • • . �
(Sec.3097,Civ.C.). ' SIOE
C1t11JdT11S P'l'
Lender'a Nome � e 4 1 2,5 0
IDMA Rei.N
Lender'S Addross 444 S. Flower, L.A. 90071 v.c.�a S 2 60�.61 Pxmit Fee 402.00 , b 9�C:� 2,5 0 0
1 cartify that I have read this appliwtion ond state that the � � iuuanca cse 1 Q.$� . LDMA P/C IF 0 9.1 6-8 7
above fnfarmotion rrect.I agree�o comply with all Couny InvesriQarfon F�a
ordinances and laws relating to building tonatrutfion, toral Pso �i 12�..$O . l�lNA Perm.M �
' and hereby ize e resentatives of this Counly to enter
�b upon 1 e a - nti ty for inspadio�{y/poses. _
X �,� LDMA $75.Oa $35.00
(/ �---� !EE R�VlRS[FOR E%PIANATORY lAN6UA6E
Siqnofuro of�pp icant or Aqent pa�e
_ _ _ _ _.
PLANS 70 APPLICANi INSPEC70R'S NO7E5 OWI�P:R-ISUII.I)1 R DLiC:I.ARR 1 IOti
� i F _.6v a"tfi�m ihni I nrr rr•.pi fr �n�,Coni . „
To; RNunwd . . Llc ma lnw f.x �he (ol , r_,� � f ie,- 7D31 5,
_ APproved � liusinessreadf'rr���ccinncCnde:�iSrs��.�<itpnr.�ountv+rbicl
Na. Date No.I Dafe � � � reyarr<r.c_u perrait.tn run.�truct,�e.lri�r,irqfrnr�,dnmuli.�b,
.�...._.....�—_._ .....,,. _�'
-- ---�—--� --_.—.� � .or r p e.�t �t . pr t t�e. �. l. .f .
. �� . ' !L ¢[J1 ,�:tjr.uli. r�tt !Y_ s�¢aJ.tf� . t
'.— .—. � ..—._,—... _.�.� __.__��. t[�at b. .�lor�nu d� r t 1 t/ p� r n� /t! [ -
. . - .. � .. . � truti sli nefue/('depf� Jl/ n < inSu tP.S c-
. . . � __ . , tlon�000)nfU a �n 3 1 thv liusin .o und P��J�s�ons
. . � �.. � . � .' � . . ' . • .��_ . L�n�leJnrtl�at/ xqercn�pte6 eJro dtLch«e�is�nrtf,�e
nllr,qed ex'cmp�inn.Anv t�iulutinn�nf Sertinn 7(H l.9!�r
.. � . . � Raquirad Oato RaeGiwd . . . � unv upj�licant(nr u pern�it suhjc��ls 11�e ufpte<nnt fn o riri!
� APproval> Yes No or Approvad� _ - ' . _ penal(v a!'����t more thamlre�c hundri�d dotlnrs(SSDOj.J:
.��__ _� -:..=�.�.�_
� �.. I,o}ownqr o��he p�opPrty,p.rny nmploye. nF
�� �� �. . . .._ -'-- wages a,thel solc eompen;ot on WII de ihe wo�k Ur•.d
�N..ai,:.���r :•ico�e - . . � � - � ,.
._�._�_�_,_.___, ' � ihe struc�ure!s no�intended or ofFered for so�e(Sec 7Ud4} ,
NeolrV pc�pornneni . .. . - ' � . . - . . . 8usrnrss and Fru��ssivax C:uda: l'I c Lnntr�.nor'x I.iccnse.
,,,__.._.—...— . l.uu�Jnos nut qpplv tn m�nirner o(prnpertv�rl�,�huiLfs
�trc��Dap�rtm?rit . . u'emprr�rus tloare.irs.ursd irLu Jucs.cral�b u�,.rk:binese(/�•—
. � � � � � . thrnufi6 1 is nuro ainplriYeea. prnrided thot sad> i.
Grndin3 - ' . . . provemamts ar� nn1 inhnd�d.� �(Jrred jnr snln /r,
� �� � � � � . bnu•errr;tfie building nr urrJ rnr�.n�an!ss.anlJ urthan nne
C.i,c�l�ogiml . _ year-o�cnnrpdeiinn. abe oumerM�ilder u�r(7 Harr tl�e
�. - � . . . . .. � .. . .. bwY(cx qf F,rna�in�tha�fie did nof 1 uild nr rrnprare fnr
PedeNrion Pro+ectisn . . . tbe/iurfuse n/saleJ, � �
lF�Pncea)IConopYl . . . . - �._� �I,Us�ownUrof�hep�oPh'�Y,nmexcJi,s�velycipnirac
, — Iing wrh Ilcpnsad contracto�s lo construcl�he proi'd(5ct. �
- � � 70441 8rasinezr and Prolv-ssrmu Cnde: 7'bu Cnn�ruclnr's
Sper�al�nspedion � :
(C:onc;IMnsunrY)iVJelding? . � . � . (,rtein.ca l.uiv dnes nol upj�ly tn an nu�nar uJj>rnnetiv u�L�n
� builrfs or imprunes Ncrenn,und u�hn t��nlru�tsJnr.surb
�loi Drain�7oe � � . � .. .. . . pr jetes a�iib a canlruetnr(sl lJ�enscd'pur�r�ant to tic
f.nrctraclnr'.s l,icensr l,nu•1.
Fo�k�no [,', 1�m e�aempt undnr Sec .8.6P.G.for rh�s
reason
— . .. Unfe �.,—. Owner
Approvals Dote InspecfoisSignOlure �
� - tNSPECTOR'S NOTES
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