HomeMy WebLinkAbout1757A 1758A WORKERS'COMPENSATION DECLARATION "� � � �
I hereby atfirm fhai I �ove a cer�ifimre ot consenf�o,e�f APPLfCATION FOR BUILDING PERMIT
. insure,or a certificote of Workars'Compensa�ion Insurance,
o.o cerrified�opy rhereof(Sec.3s00,�ab.C.) COUNTY OF LOS ANGELES BUILDING ANp SAFETY
Po�W�005-279-00]�6mPo�Y Nationwide
� Certified copy is heraby turnished. fOR APPLICANT TO FILL IN ADDRE55
� Certified copy is filed with the counfy building inspeo BULLDiNG
tion department. ADDRE55
Oote 7�30�87 Applicom �� �DIN ��� CITY Diamond Bar ZIP 91765 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BL�GS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT Now Onl iOT cRoss sT. Diamond Bar $ZVC� & GOZCIP_Tl S rin
(This saclion need no�be mmpleted if the permil is for one ASSESSOR
hundred dollors($100)or lesz.) TRACT 42579 BLOCK LOi NO. Z4 Mqp Bpq( PAGE PARCEI
TEI. U55E ZONE 1v1AP 1���L.
I terfify ihal in the performance af fhe work for whi[h fhis OWNER NO. _ (�^I NO. t '7
�� � SPECIAL �
permit is issued,I sha�l noe employ nny person in any monner qODRE55 P.Q. HOX 3329 g(�p COr�OinONS
so as to become su6ject to fhe Workers'Compensafion Laws. U
QTY ZIP
��''ie APP�imM � ARCHIiECT OR TEL.
JTICE TO kPPLICANT: If, ofter making this Certifi[ofe of ENGINEER Np DISTItICT GROUP iVPE FIRE PROCFSSED BY �
Exemption, you should become subject to the Workers' — r(�' CONST. �ZONE^ U
Compensation provisions of�ha Labor Code,yau musf forth- qDDRE55 314 N. F'1Z'S Cd ia �1 p R � .YK— ���M e a
wlib comply with such provisions or Ihis�permit Shall be TEL STATISTICAL CL4551FIGTION APT. CON�O. (p
deemed revaked. CONTRACTOR NO. 11 Z
UCENSED CONTRACTORS DECLARATION � �iC. C1A55 NO. �Ud DWELL.UNITS�
I hereby affirm thar I am licensed under provisions of Chapter 9 ADDRESS �S c1�70V2 No. 510560
(commenting with Secfion 7000)of Division 3 of fhe Business and ��� SEWER MA9 .
Professions Code,and my license is in full force ond effect. CITY CLA55 BK � VALIDA710N
510560 B sI�FT 1314 sroR�s 1 AMi�es 1 CONEK �
License Number lic.Claas
� VALUATIpN
Contractor THE ANDIN GROUPDate 7-30�87 �XRIMION OF WORK N�
ADo SbS,ZOO ;:1757A
❑I am exempt under Sea � , �,�� � ���
AITER
8.8P.C,for ihis reason REPAIR � _ �
Date: USE Of DEMOL � �z��,S�
EXISTING BLDG.
Signature APPIICANT TE4. FINAI /f � 4�"i.���'�
OWNER-6UIlDER DECLARATION vRIN'r N0. . DATE �/�/��
I hereby affirm that I am exemp�from the Contractor's License 0 4,1 6-8 7
Low for�he following ieason(Saaion 7031.5, Business and ADORE55 AS 1}�OVO FINAL�/�v6�f —/
"'��ofessions Code): dY �U��'��b�j�
� BVILDING
1, os owner af rhe praperty, or my employeas wifh ADDRESS
_ wages as ihei�sole compensa�ion,will do the work and � , <� 7�c�"��
Ihe struct�re is nat intended or offered for sale(Seclion ��`��TY
7044,Business and Professions Code�. n�ovwG TE4 fr• s• o • �
� 1,as owner of the propeny,am exclusively contracting C NTknCTOa NO.
with licensed conrranors to consnuct rhe projetl(Seo- � °3�2���
fion 7044,8usiness ond Vrofessions Code). /+DDRE55
CONSTRUCTION LENDING AGENCY SET�BACK YARD HWY T�TApR P UNE WiDTH 6 " ��'G C�
I hereby affirm�hat there is o cons�ruction lending agenty for FRon,r �0?.1 6--8 7
the performance of the work for which this permit is ias�ed V.l.
(Sac.3097,Civ.C.). SIDE
'..ander's Name
C1t.lbc"IYI�C P.l. ..
444 S. F1oW2T� L.A. 90071 P.�.fees 233.84 ve�mirFae 361.50 �onv.Rsr.x
ander's Address ,
=ertify that I hava read this application and atate that the issuan<a F.s 1��.$d . IAMA V/C A
xve information s correct.I ogree to tomply with all Counfy 1n�eatipatlon Fae
dinonees on te laws rebtinp to building eonstruenon, iowi P�. 3 72.OO � LOM4 Parm.N
�d hereby orize rapresanlativas of thia Counly ta anter
�o the ed property far inepection p posen. _
�/� fE!REVE�SE FOII EX�LANATORY LAN6UAG[
� Siqrwluro of plfmnf or Aq�M Dcla
PlAh3 TO APPUCANT lNSPECTOR'S NOTEB� .' C)�ti'�Ftt-13UII.U}•;i2 UECI.AN.'��ffUA
I he�ek�,y n44:rr� thal I o-�eze�nui trom Ihe=(;onvo��.c�"s
70: _ RNurned � . . Gcense'Lav, for ihe (ollow�..ng r,.,.,.� lSer.� 70Jt 5)
-'� APProved - — l3 c.�. nIl r 1 n�( d ilnb ut� � u�tt�i f i l
Ma.( Data vv Mo. - Dafe � � - . rcyu .�uh�rn t( c s!arc! .�It.� auj�r� d 1�.�1
_��..�..__r� �_. -� �_�__ � �� r, „� � �G ,fi < < ,.�., � r ,
� � �� !/>,¢hplr�w�t Jr x�i pi nirt t /alr n s�G 1 sf t_ �n7
--- �—�—�—�--� -- e5ut 1�o li�ens d(e�rxu� t t tG��p� ��u' n,oI rJ (:�m
tr �! r.1 i�e . 1�u�(Cl���ter lJ/a'm r <no�n,q u�tl.1cc'
—�----�— —. trun?{Iq(II n(,D reon 3 0/tbr Nuvai �-�nJ Pr,/. .
.. . � . � . . . .. . . • " . CndeJ nr th�t`I e i.r ezrunrpt t!emlrunr anJ�Fr�hne�ic fur tbr
— aRe,yr•d exom�tmrs.AnV<�h>latron rr�,?ectrnn '1147.5 hY
Re uir6d � � � � � li�u t r� ermel b e�1a f6ea !ac¢rnt( ririf
i 4 Date Received °Y ti I h � " r° �1' I Pl'
ApPro,vals � ar Approved . . . � _ pan�ltl'��7�nnt n�nro eb�n/ .bendr d d d1«c�($SOp/.J:
� Yes No . . . .
�,.__..__.._..___ _ . _.__.—. �_ I,as owner of ihe p a1 F'�Y,o�. y emnloyePs w+h
_ .._......� _�` ..
yy���,�., � _�;{,����p � ' ' � _ . wog9s q=�helr sole compensonon,will�]�>the H�orp,�nd
____�._...._ —.. _. . tl�e struct�re is nnl intended a�offe�ed for sc'�le jSc:.7044;�
Healih�UeP�•�rnenr . . ... � ' . . . i3usiness and Pnrj�csiovit Cud��:7�h��[:onVa�ti�r's l.i,ense
._. .. ..._. ,. . .
l.au J ic n 3 afpJ�m an v r nJ pr p !�.•u�/� l.uihlx
Gl.c D �_nmvn• _ . . — a e nJ rr .:iE.r ,�nd i b J u.e ni�F ioork Ri ��//�' ,
� . � fl �uhb hrx a�n�ernpliiyc.� prorar!d tbut su b i
rod 3 � - �..� , -J�rnternr.nu,«rr nnt inkndad r i/(<. d/rar sale. !J,
� ' {i;. ,�_ � i .. � . . . � , � b e r the buildinX nr�»+/rm�n�ent a ld u etlo�n nne
Cea!eg�cd - N<ur /c rrrhlolintt, L5c riu�nar-builde x.tll hrsie tho
_ " _ burl n f pruvin,q Ihn�bc Jid n.,r hr rld i�np c,/nr
Pe�K�an Prutec»nr� � -----.-- tb /�ur�ioae�nf sn(v/. .
�(Fenwj IConopy) � .. - . -- - -� � ���.i. I.os vwner of tha property,om e el_ Iv�ly con•�nc� .
�^- —"— 1! G�n h I c-ensed co I oUo s to conslr�et thr proiec!;Sec
�SF�rc ol I peU'un � � . � . . . . . 7p44)H s nses and Yrn(e. r � C Je. 76r Cr�ntra�tnr's
Con )(,Uasonryj�Welding) . 1. fa�e d. s tuppJ�i � un r uJprnperey u/>n
I � hurlJs nr i�nTrrrt<s lbernon,�xnd u�[zn��nntrac[a Jnr aurb
,ot D�c�,naoE^� � . . � - . . . . �rnic<�ls-a�(fb a cnnfracturlsJ!i<en.dsd�urcuant tn 7l e
- � - . Cnnarnrinr'.r A,icense I,rnrl. � � .
Pa�kl�g � � . ,_ I um r...einat�mder Sec. � .8.8P.C.fo�this
rA�son
� . Da+e . . . Own. ..._ _._
ApA�ovals ppfe Inspectoi s Signalure . � � < •..
� 4��__� '��€i� IhSPECTOR'S IdOTES �
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L cu'c.�� - _ /�v"r �
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faundatloris __ _ _ . � . . . . . .�._.._�..
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F,a.�,� �,� �.7 _�Z� ____. _ _ �
ene�rgy ins��aron � J �j —._C�" "�' � - � � �� . . �
latF..�Urywai'-. ���3 � _�„/� . . .
�nterior ��v�
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h Ex�eno�� — . .., � . . — .—'—
No��se Nvmber_ . . —.
Cor.rct&Posied � � `
flnol - - . .- . .. . . -� . .
Ente�on Fronl . � . .
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