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HomeMy WebLinkAbout1721A 1722A � WORKERS'COMPENSATION DECLARATION "'- � � � . insuroborofcertif�a'�eof�WokesrrCompe�so�onalnsurane" APPLICATIOIV F4R BUILDING PERMIT � or a eertifled eopy rhereof�Sec.3800,�ab.C.) COUNTY OF L05 ANGELES BUILDING AND SAFETY Po�W�005-279-00]L6omPa�Y Natiornaide Certified eopy la hereby furn�shed. FOR APPLICANT TO FILL IN BLIILDING ADDRE55 � Certified topy ia filed with the counry building inapec- BUIt01NG tion deporiment. ADDRESS 6]_� }Sy'fiLltpS Place pp1e 7-30-87 APPIicaM T� �IN �UP arr Diamond Bar ziP 91765 �oG,uTr - CERTIFICATE OF EXEMPTION FROM WORKERS' SRE OF lOT NOW ON LOTS C O55 ST. D1clITiOIICI BdY BLVd & GO1C�@II Spring COMPENSATION INSURANCE (This secfion need not be completed if Ihe parmit Is for one � ASSESSOR hundred dolbrs(5100)or lesa.) TRACT 42579 BLOCK LOT NO. 23 MAP 8001( PAGE PARCEI 7EL. �7 �7 I certify fhat�in ihe performance of thv work for which ihis O`NNER NO. _ U�ZO;E NO. 1 /"3��7 permit is iss�ed,I shall not employ any person in ony manner � SPECIAL so as to become subjecl to Ihe Workera'Compeniation Laws. �°�DDRESS P•�. BOX 3329 ��DO CONOITIONS � U ��ro Applicnnl CIiY ' ZiP '] � OTICE TO APPLICANT: If, after making fhis Certifitate of ARCHITECtOR TE�. DISTRICT GROUP tt�PNST Z�NE PROCESSEDBV �O Exemption, you should become subjetl to the Workara' NG�NEErt Dave $2dT1 1�TA r,o.445-4073 � Compensotion provisians of the Labar Code,you must forth- qDDRe55 314 N. First, Arcadia 91006 Q R-3 'rnn`a,� W ilh comply with auch provisions or thia permif sholl be � n-' deemed revoked. TEL. STATISTICAL CLASSIFICP,TION APT. CANDO. (n CONTRACTOR NO. ,�� LICENSED CONTRACTORS DECIARATION � ���, CLASS NO. �Qp �WEII.UNITS.� �^ 1 heroby affirm that I am�icensed under provisions of Chapter9 AWRE55 � �Ve Np,51�560 (commencing with Section 7000)of Division 3 of ihe Business and . ���, � ��R�P P�ofessions Code,and my license is in full force and effecr. Ciri CiA55 $ 8K � VALIDATION 510560 B si°iF� 1409 s"Toa�s 1 FA°ii°es 1 CONE i licenae Numbar Lic.Class VALUATION Contractor T�S �D.� G��Dote 7-30-87 DESCRIMIONOF WORK $1R le famil A D ❑ s 7 2�$QQ ❑I om eaempt under Sec. � , ALTER �� �I Z� A B.BP.C.for thia rooson REPAIR ❑ � s �ote: USE OF DEMOL �{°•a •2� EXISTING BLDG. Signature APPUCANT � TEL, PINAL � •2 4 Q 5 5 OWNER-BUILDER DECLARATION PRINT NO. . DAT@ � 't�� L hero6y affirm thot I am exempt from the Contrac�or's License j{5 �OV2 • •�4�.�5 z Law for the following reason{Section 7031.5,Business ond ADDRESS FINAL � �^•ofessions Code): � � �Y 0 G,� b—a'� � BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole campensation,will da the work ond ����n , , the structure is not imended or offored for sole(Sectlon 7044,Business and Professions Code). nnOV1NG TEI. � I,as awner of the properry,am exc�usively contracting CONtRACTOR NQ �.� 7 2.G A with Iltens�d contractors to construct ihe pro�ect(Seo- qDDRE55 tion 7044,Business and Professions Code). � f! � � �.� �r CONSTRUCTION LENDING AGENCY SET�BACK YARo Hwv TO7A ROP.LWE Wiotii I hereby offirm thal thete is a consirunion lending ogency for FRONT ( °�9��0 the performance of the work for which this permit is issuad P.�. `,�,�O�_ (Sec.309�,Civ C•)• SIDE � - � Lender's Name Citibank ".` 0 9,1 6-8 7 LDMA Bef.N � m 444 5. F1C7wer� L.A. 90071 v.c.F�s 244.55 pe�mnFee 379.50. , ` Lender's Address � 1 certify that I have raad this epplimrion ond atota that 1he Imuan<e Fee 1 O..S O . lpMq P/C M above iaformation is mrrect.I agree to comply wi�h oll Coumy Invesrigarion fee $ ordinontes a tate laws relating to building construcrion, Tmal Fee 3�J O.��� LDAAA Perm.N R and hereb orize repreaematives of thia County to enror � upon th m ed roperty for inapec�ion purposes. /// LDMA — $75.00 $35.00 F ��«n � SEE REYERSE FOR E%PUNATORY LANGUAGE SignoNre o1�f�pplimnt or ABeni poro PIANS TO APfiLICANT INSPECTOR'S NOTES � - • � ON'%'VI{H-Dl.'11.I�F.H UECLARA'I'10A' - . . I h��rrEy offi�m lhat I c�rc,ex_mp�tn;m I',e C:ont�u;_rc�s 70: - . , R�tdrrwd �... � . . :ic<;nse lnw'.fo� •hc• foll rg '�>"i�... rgr�c 705'.. i) APProved — Hns�nvs�nnJ(r! a uns(rJ. t�n}���rt� ir nenti i bicb � No. Date� No� Date �� rryurr. per f t nncir t .lt.� r�. .. d�� !�.l, �... �. . .�:�_.._.—.. ______"_�'. , ..__�.- _ --_�--.--..--� . f uftp a7r ct n,hra r I rt sr � ul y a . ���� - I!>c u�h&cunt( . u-6 hernut trr�rlr a saSued.�[�tenvyul �----- -- ---'— �— ehu:Gr is Jrc�nsed pussuunt tn i!r prori.r�inas n/1he(:un- - �� . . . . � lrmclur's l.iren.ce-!„trr/Cb✓pirr)J/conm:rn�in,{u�itb.lec' _.�.-- _.. _�_� _ .. . Non7000JrJC)irid„n3n%thel3usixessenJPr„/rc,ron< . _ . . . � . . . � .' . . .. .�Cndr/or rhu([ � .en�pt tLerr/r��orr nd�l,c hrn�ro�lor rbr nlle,qeJ r_rampf.inne Arsv viulatinn nf Scrfiorr'f137.5 hy � � -` �Raquired� Da}eRaceiwd � -� :+nvuQP����nt�r�rrtr��rneitc+ihjeitslh�•nfJl��nnr(uu,i:d APPro�als - ... . or Approved . - . pr altv n('nar morc tbun/:rc 1 irnJnJ d 11nre/a S00i.J.� . �� Yec No � . � � .., � __.—_�._._—._ ._.. .�_ . I,as owr•.er of fhe propr.rfy,oi my emnloY�"s wrth `N��ter Cen�Rcate ` '�� ' . - � . � , - wuyes as�helr sole corc�pensahorr,will dn Ihe work,and �__ ��_-� � _ tfie skucwre�s nol iniended or ofFered fpr sal=�Se<'704dJ Healtn�epnnment __ . ��. � � � - . (3usir�ess und P r2/essioxs Cnde•77�c Cnnir,��eor's l.icense .. � l.au�dncs nut upplv tn ur�nirner nJj�roporrv u•kn 6uilds . FirE Deportment . _ _ . � . - �r im/rne�v.v iherv��n,and u!n�loes snrb v�nrk l�imsol{,v- .. . tlrouKh his nu�m ernplqY�'�'��, prue�rdeJ tlat .ruch h Csrndmy , r ,.� Jrm<�eme�rsts arP nnt ia(endeJ or u/Jered/ur uelr..O,. - . � � . � . - . ,. .� Gmoeuer,ttre breildin,�or irnprnnement ts sold e�itGin nne Geo�oyicoi. .... . .... . � t�e¢r hf enmpfetinn, ebe.au�narbuilder iri!!Arurr.the - � . � - - Gurdcn�f prneinfi Ibu1!�c did nul huilJ nr impmrn/nr .. �. - � . . . . � tHc purpose nf s�drl. . Ped+sS+riuc�Protattlpn ' . . � . � pr F y,'am e ius'.vel• I c rFence)�C�nopy) - � �� �� - � � �1 I,asawnerofihe n�er? - �canw � tiny wrth ficcnsed conlroUo�s ta<onstruct rhe pro�ac�(Sec. Spr�clol Inspectlon � 7044j Uusinase�unJ 1'rnf�'��rinne�Cude: 7�be Conlra��d�r's (Coi�<.1(Masonry)(Welding) � l.ioense I,ua��dnes nu1 u�plY tn un nxri�vr r f J�rnpnrtv a'Lu� � � . ' � 5urlds�nr irn/�rne���s lhereon,arid u�bo i onlmcts Jnr suah Ln1 Dromr�ge . . , . prnjcrte udtl� a cnn�rudur(s/Ii.en.u°d/�ivsuant 7n tJu � C'nntrartnr's I,icorise l,uu/. � � A�rkinn � �" � n 1�m e*empi unde�Sec. .6.8P.C.for this reason . � - Da�e C�wner Approrols Date laspector's Signotura � � �� � .IKSPECTOR'S N07E5 � locallon..' — __._«..�.�._ ` ^ �� �3~ �� . �L�� .. ._ {Se�back&Yordsl � fuundotlons , . ��� �� �' . � ,f}C/L' � . . . • r� Slab _._._... _......-�- . . . Frnmr � �l�t7 �f � . . . . � . Energy Insulprion �� �6 fii ' � T Q/ 6a�t,lGywai�-- � . - . � !���e�ior // .23 �'7 �� � —�_.___ � ______ t�rh-exre•'��, 6?N 7 './-6Cf � . . . ._ . . - . H.:,isr.Nurnbe.-._- -_ _._.__ ,.� . _ . _ ..— - .� Cerrecf 8 Pos+stl 4 . . . � FIr.aI . ... . . . — — E�Ir�n�ProNA_ _ ^ �' �—�...� � ! �. . ` :..' _,-- �. .—T--' ___.�_'__.._ �� '.. " .�_.__._.._.J.__ _��. _—_...—"_—' . . . �_.___._^ �.��. '�'_"__.` . .. .._. ♦��� . .. \_' `� � _