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HomeMy WebLinkAbout0769A _ . . . .: _ WORKERS"COMPENSATION DECIARATION �����' � ';�-� -. �..�- . � ' I hereby affirm that I have o certificafe of�o�5e�,fo 5e�f �� - A6'PLICA�'ION -�OR BU,IL�DING PERMIT -��� insure,or a certificote�of Workers'Compensotion Insurqnce, or a cerrifietl copy thereof(Sec.3800,�ab.C.� ' CQUNTY OF LOS ANGELES BUIIDING AND SAFETY Poi��y��3WC005-279�g,Q�y Nationwide 1/B _ � Certified copy is hereby.furnished. . . FOR APPUCANT TO FILL IN bUILDING ' ADORESS 1 O P�. (1 � Certified copy is filed with Ihe tounty building inspec- - gUILDING - L� tion departmeot. � � ADDRE55 615 Armitos Place .. oare ��8�87 npplicanr THE ANDEN GROUP cnv Diamond Bar ZiP 91765 ���in, Diamond Bar CERTIFICAiE OF EXEIvlPT10N FROM WORKERS� � Si2E OF LO7 � NOW ON�LO75 � CRo�ssESsr.� Diamond Bar BZVCl./Golden'S YlII S � COMPENSATION INSURANCE� (This section need not be comple�ed if the permit is for ona TBAC7 QZSJQ BLOCK LOT NO. A��� � bundred dollars(5100)or,less.). . � MAP BOOK PAGE� PARCEL � TEL USE ONE N�4F '` OWNER THE ANDEN GROUP' � No96�7-95 1� I ceniiy that in the�performance of�iha work for whi�h this tt �� - � r '��'Y� � parmit is issued,I sholl nof employ any person in any manner _ pDDRESS P.�. BOX�3329 � SPECIAL '� � � � ��d so'as fo become subjetl fo 1he Woiken'Compensatioa�aws. dOd CONDITIONS u ,/^�•_ . .� .. . Q7v . . ZIP . .. . . � . . . . � � te - �- ApplicoM � � � � - ARCHI7EC70R � TEL. � � � nOTICE TO APPLICAM: If, ofter making this Certifimte of ENGWEER Dave Szan E��a rio. 445-40� o�sre�cr .�aouP 7YPE . FIRE OCESSEDBY Exemptian, you shouid become subject to the Workeri � � CON�T.� ZON Compensotion provisions of the La6or[ode,you must forth- qDORE55 314 N. First Arcadia 1 �� � �3 � � � �� a' with comply with�sach-provisions a this permit shall be . . . y deemed revoked. � „ � TE�� STATiSTIULL MS FICATION . APT. CONDO.'. � �Z CONTRACTOR Mp. LICENSED CONTRACTORS DECLARATION�. � .. ... . .. ��� . . CUu55 NO. DWELL.UNITS � I hereby affirm ihaf I om litensed under provisions of Chapter 9 ADDRESS Np, SEWER MAP � (commencing with Section 7000)oi Division 3 of the Business and . ,. . ._ . ���, � Professions Code,and my license is in full force and effect. CIiY Cu�55 B � BK. � �� � - - VALIDA710N � � � � 5�.fT. NO.OF NO.OF CHECK . . � License Number 510560 i�c.eiau B ' s¢e 1535 STORIES L FAMIUES 1 oNe � � � � VALUATION Conr.acro� THE ANDEN' GROUP pate]IS�H7 DESCRIPT�ONOF WORK S1R le F8IIL7L NEW � S 7,809 ADD ❑ , �1 am azempt under Sec. � � �� � �-� �� �... .�. ._ . . ....... ❑ ALTER B.BP.C.for this reason $I+AB ONLY �pqlR ❑ � _ �' - ' ' ` z 0 7�9 fl� " Date:� � USEOF pEMOL . . .. EXIS71NGBlDG. . . ��•.a.w e � � � Signature . -. . . . DA E� / . .-�... � m- . APPlIG4NT TEL. !� _ OWNER-BUILDER DECIARATION ���'�T T�+' �+�EN OUP NO. � 1 p 7J _ I.�� ..7 a,2..Jr �. � I hera6y affirm thot 1 am eaempt from the Contractor's License � �`�+w for the following reason(Section 7031.5, Business and ADDRESS S3IDH &S 8UOV2� FINAL ��� u e = %�(J,F'Jo , �fessions CodeJ: � pR N 9y �� �6 � 7�s 7 . .� Bl11lDING . .,, . , . _ . I, as owner of fhe properly, or my employees with ADDRESS woges as�hei�sole compenmtion,will do the work and ��p,��iv � '�'' � � the srructure is nol inrended or offered for sale(Section ' � ' , ' . � �7044,Businezs and Professions Code). � MOVING � ��� ���� iet. - � � � �� . � I,as owner of the property,om exclusively mniracting CONTRACTpR NO. . , �� . . � � wiih licensed coMractors to consiruct the project(Sec- qD�RESS � fian 7044,8usiness and Professions Code]. � . � CONSTRUCTION LENDING AGENCY�� � REQUIRED .yqRo Hyh, ioiat 5E78ACK .. _ . . _ . .. . .. SET BACK PROP.LINE WI�TH I hereby affirm that there is a cons7ruttion lending agenty for FRONT � � � � ihe performance of Ihe work for which fhis permil is issued - P.L � - � ��-�-- ' � �- -�- � - ($ec.3097,Civ.C.). 9�E .. . � Q1t1b8IILC . . . _ P.L. . . . . . .. . _ _. ._ . . Lender's Name , ; IDMA Ref.N � � � � � Lender's Address 444 S. Flower, L.A. 90071 P.c F�e s --� ve.m��Fea 63-.75 - � '� . -�- � . I certif ihaT 1 have read this a licotlon and.stote ihat the . . 10.5� .- _ Y PP � Issuance Fee LDMA P/f k - ��� - � obove infprm n is corrett.I agree to tomply with all Counry ���astigation Fee . ; ordinance n Sta1e lows relating fo boilding construclion, ,, , . � To�ol Fee - �']t}. IDMq Perm.M �� - - � -� � ',r �and her y 1 Nze representatives of Ihis Caunty to enter upon 1 e- roperty for inspetla.i�on purp as. . Q/ �� SEE REVERSE FOR EXP4ANATORY MNGUAGE .-.. Signnture of Apphcant or Agen� � Dare . ..... . �. . . . -. . .. .. . . ... . . .. �� VLANS TO APPUCANT INa'PECT?k'S NOTES OWNER-BUILDER DECLARAT101V . I hereby affirm thal I am exempt from ihe Contractor's To: � � �. RatUmod� � , � License Low for the following reason,' (Sec. 7031.5� � � ' � � Approvad - Bsssiness and Professions Code:Any city or cossnty mhic6 No. Dato � No. � - Dat� ��� � �� - � � � - � - reguires a permit 10 constract,alter,improve,demolisb, , . . .. ..-or repuir hny stsucEure,prior to its Tssssawre,also ieqaires' - _ - . � ,. � , , , � - the applicont for suc6 permet to file a srgned atat¢ment �� , . , t5at be is licensed pursuant to theprovrsions of tbe Cop- .. ., _-_� .. � � - tractor's Licease Law(Chapter 9J(commearing with Ser . , - ;� tion 7000J of Divisinn 3 of tbe Business and Professioxs . . ._ . . . . _ . �... . .� . . �. . � ... . , _ . . �... . . �... .. CodeJ or t$at 5e rs exempt tberefrom and the 6asis for tbe �olleged exemption.Any viuladaa of Section 7031.5 by .- ' _ -Requirad � Dafs R�ealwd- � - - -- � �� � any applicaxt far a permiL aazbJecer tbe applitaxt m a rivi! Approvals ar ppprovsd penalty oJ aot more tban fie�e bandred doUars(8500/.J: Ye� No � �� � � " � �� � � � ❑ I,as owner of the properry,or my employees with Water Certificate _ � � .,_ . . . , . � . _. . wages as their sale compensalion,will do�he work,ond � � �he slrutlure is not inlended or offered for sale�Sec.7044) - Health Depariment ._ . _ . � . � . . � - - �- '- .... . Busirsess and Professions Code:Tbe Controctar's Licease Law does nod apply to an owxer of property wbo bui(ds Flre Department. .� . � ' . � �� � �� - --�� ��� � nr improues tbereon,¢ad wbo does sutb work bimself `� � � -� , - � - � �� tbrougb 6is oum employees, prooided tbal sucb ir.. 6roding � - �, .� � . � prooeme+ets are noa inteeded or affered for sale. If, � - . • �- - � �.. bou�ever,tbe building or improvement is sald wilbin one Geologicdl .� .�- -. �- � � year of tompletion, fbe owner-6ui(der wiU�baoe the _ _ �;� ', � - brerden f pmuing tbat be did not heild or improve for � ' '`..�., " tbe purpose nf sale/. . ' � �� .. Pedestriao Wotectioo �. � � - � �Pence)(Canopy) , � �. . � � � - -- � - - � - � ❑ I,as owner of the property,am exdusively confrao- - �ing�with licensed conhacrors to consrruct the project(Sec. Special Inspection . , � � '� �� 7044)Business and Prnfersions Code: Tbe Conlractor's (Conc.)(MasanryJ(Welding) � � � - � . . . . . License Law does not apply to an owner oJp.ape,:y wbo � � . -�� � � - � duilds or improves tbereox,�and who contradr for sucb Lot Drainage � „ . , - . _ ,. .. , .. . projects mith¢contracdor(rJ licena¢d pursuaxt to tbe -'Contra�tnr's License LawJ. � � � �� " Parking � . .. . _. '. ..._ . . . � � � � - , ❑ I am exempl under Sec. ,B.&P.C.for this reason � Date Owner Approvals Date Incpecfor'�5ignature � . . , � -� INSPECTOR"S NOTES � ` ^ Location— � � . �Setbock&Yards) �- - � � �� . � � Founda�ions � � � - " Slab Frame Energy Insulotion � � � � � � � . . . -. � Lath/Drywall— � .�. . .. . . ..-.. � � �- � . Interior �� � " - � - - Loth-�Ex�erior , � - � � � � - � � � - House Numbar— � .: . . ..._. .. . . � .. , � .,- . . . ,, . . . � Correct 8 Posted � Final— - - -- - . . . . . --. Enter on From �� � � � . . . .. ... . . . � . . 1 , . . �!'-. ' ;._ . . . , .. � ... 4�:, '�`. _ . , 1