HomeMy WebLinkAbout1719A 1720A WORKERS'COMPENSATION DECLARATION '�� ' "�
I hereby affirm that I have a certificate o,consenl lo„�f ' APPLICATION FOR BUILDING P'ERMIT �
. insure,or a certificaie of Worken'Compensatlon Insurance,
o carrfie co rhereot 1Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
�/�Wc00�-2�9-0016 Natiornaide 3 A
Po iey No. Company
� Cer�ified copy��bereby Fur�ishad. FOR APPLICANT TO FILL IN Bl11LDING
ADDRESS
� Certlfied copy Is filed wl�h fhe eounty b�ildinp inspec- BUILDING
lion deporfine�f. ADDRF55 616 Armitos PlaCe
ome �-30-87 APPlicant T� �IN �� cirv Diamond Bar Z1P 91765 ���iTr
CERTIFICATE OF EREMPTION FROM WORKERS' Si2E OF LOT NOW ON LOTS CRO5555T, DlalilORC� BdY' BZVCI & GOLCIP.II S L'1T1
COMPENSATION INSURANCE p g
(Thia eection need not be eompleled if the permit is for one TRACT 425�9 BLOGK lOT NO. 25 �ES50R
hundred dollare(5100)or leas.J M�4P BOOK PAGE PARCEL
iEl. n
I certify thot�i�Ihe performonce of ihe work for which thia OWNER NO. - U�ON�E NOP .I <-3 ti 9
permit is insued,I ahall not employ any perwn in ony manner P,Q. gpX 3329 8 SVEQAL �
. so as 10 become subject b fhe Workeri Compensation Laws. ADDRE55 �O� CON�ITIONS �
GTY Covina ziP 91722 � V
��.te Appliwnt �
JTICE TO APPIICANT: If, ofrer making�this Certificote of ARGHI7EC'f OR TE�• DISTRIC7 GROUP 7YPE fIRE PROCESSE�BY O
Exemption, you should 6ecome subjact to the Workers' ENGiNEER Dave SZdIl AIA No.445-4073 CO�NST^. l' �ZO(N/E� �/'y� t U
Compensation provisions of ihe Labor Code,yOV must forih• qD�RE55 314 N. First, Arcadia 9 10 0 6 1 0 �� �U- I� J.s�" 1'�0.1Cne W
wilh tomply with such provisions or this permit shall be �� d'
deemed revoked. CONTRACTOR � STATISTICAI ClAS51FICATION APT. CONDO. tn
^�- Z
LICENSED CONTRACTORS DECLARATION AS 3}�OV2 "���510560 «j0`55 NO.�OWELL.UNITS -
1 hereby offirm that I am licensed undar provisions of Chapror 9 ,4DDRE55 NO. $EyyER MAP
(commencing with Setlion 70b0)of Divisian 3 of�he 8usinass and ���.
Professions Code,and my license is in full force and effed. CIiV � C�A55 B VALIDATION
510560 B 5Q � 1409 "o.oF 1 n,o.oF CHECK B1 �
License Number Lia Class SIZE STORIES FAMIUES� �- � ONE
�II', �',� �UP 7�3O�H7 DESCRIPTIONOFWORK rJ1T1 le famil �A��ATION
Conrroctor Dme A o [] f �Z'8 Q a ' r 1 7 1,9 A
❑I am exempt under Sec. GdLd 0 4FiZ SF ❑ �
Al7ER ��v • •'2�
B.&P.C.for thia roason � REPAIR s
� USEOF 1 •24455
�fe' E7(ISTING BLDG. DEMIX
APPLICANT TEL • ^-�L4 U�S Jr U
Signature � FINAL ?,,, ��
OWNER-9UILDER DECLARATION vRiNT NO. DATE �
1 hereby affirm�hat I am ezemp�from the Convactar's ticense � a�Ve � 0 9,� 6'-�7
Law for the following�eason(Sectfon 7031.5, Business and ADDRE55 p�Np�
�•ofassiana Code): � � !y
JBUILDING
I, as owner of the property, or my employeea with ADDRESS
wages as their sole compensotion,will do ihe work and �Q�A��T� . '
tha afrucWre is not intendad or offered for wle(Sedion �� 7 2,�A
� 7044,Business ond Professions Code). MOviNG iEt.
� I,os owner of rhe properry,am exclusively eoniracting CONTRACTOR NO. �a� � � � �
with licensed contractors to consiruct the pra�ect(Sac• qDDRE55 �W
tion 7044,Business and Professions Code). . � 9 Q,Q Q
CONSTRUCTION LENDING AGENCY ��gq�K YARD HWY tOtA�p�SE�ip `WE WIDTH ^J;9 G,O O�
I heraby offirm thm there ia o conatruc�ion lending agency for FRONT �
the performance of ihe work for which fhia permi�la iesued a.�. 0 9,1 6�8 7
(Sec.3097,Civ.C.j. SIDE
Lender's Name
C1t].b3I1�C P'l'
2 4 4.5 5. Pe��„n F� 3 7 9..S O . LDMA Ref.M
m Lendar's Address444 S. F�.C7WPS� L.A. 9�O�J1 P.C.Fea S '
� I certify that 1 have read ihis applica�ion and slate ihat the " Issuance Fee. �O.�50 � �oMq piC M
above informatio corroct.I agree to comply wlth all County In�es�igarion Fee - -
ordinonces an e lawn relating to 6uilding�o�ar.��rao, � T,,,i F,a � 3 90:00 � �onu ve�m.r
and hereby ut ri e represantatives of thia County to enter
upon the e operty tor Inspeclion p poses. L DMA -' $7 5.0� $3 5.00
^ O-Z/�-.�O � SEE REVERSE FOR E%PLANATORY LAN6UAGE
Signatu.e o4 Applicant o�AgeN Date �
PIANS Tq AP?tICANT INSPECTOR'S NOTES .' � ` � U1VM1!K.BI.!]I.UI R UItCLAH4 f10\
I h_et.�y a4f� .hot I o� e -�p�fr _.e Cunnuc�r.r"s
To: . R�Surindr , � . l�tens? Law fo� rhe fyliowinq r.,.�,., !Ser: 7P3t 5!
ta
ApRroved -------- lie .und I j..-� ( d 1 r iry tt !�:1
No. Dafe No� v O te rey¢ . �e Trr rr t� � .t t !t � r j� J f.(
._,-.�_...__� ..._..�_ __.._�. ur r pa �an v atrnd:�n../r r f,rtc issrmn..�.al.v ru/riire�
_ . ""'—_�._ ._" _'__ ._____
f.`_'.___' '_—#' . .
� . . , ' t!>s¢/,pllrurit Ji,r eu�h perniit 1n/i(r a.cie���':!stretemrwt
+ ..�_. .. _ .1Got!c i.r liccn.s�-d p��rsre�n�1n tLe prurde�n�rss n/�he Cu.r
��-��' � .� ' � . � ero��tnrk l,lrcnsr l.�re�(Cl�upler l/(aua�n�rncL��xcit!_�Srr_
--�--- --...--- tion 700lI/07 Diricion 3 0!thc Rusinrsc r�nd Prn/,�asi„ns
. . . . � . � . �. .. . _ � �(:ndcJ nr tba!!e is rscn�pt tl err Jroni anJ thc bar�i.c fur!!e
a!lr,QcJ exampteors.Anv ninlatrnn r�/.Sertiun -V31.i h}•
. � Reqoired .. . . . anvupplicant/nrofrrrnril.svh/<r:t.cthrapp/rcnn�tna�:iri!
A rovals �afs Raeaived � � ,
PP. or Approred . . prnaf�v n/'nnt rn rv�tb�n/irr.ln�ndrvAdnllars(.S91iU)./:
� - _�Yei No �^ . . .
-_� � _„__.._�- � ' � �_ I,os owne�of rhe pro(,�vr4y,or my p�mployeP=w��h
Wai�r Cerdlm�e � ' wagas as�hen snln<ompensnt�on,will do�he wortr,.m•,�
� �� " � . the s?ructu�re is no!�.�nended ar ofiered(or snle�Sec 70ddj
NeaL h Deparrment .. . . . - . . Drarnrss and Prvfrssinn.c CnJrr 72re(.'ruKrde�tor's I.icense
. . . . �l,aw�Inas nat applc����n u��mrr o!properlv u�H,�huild�
Rre�epanmoni . .. . - or imj�rnr,ea tl>�rrenn,rrnd�e•l�n dnas srRrh�rnrk;Li.usell�.
_ . . drrnu,qLr bis nu�n ern/�IuYRPs, JruriJe�J tbat surL i.
G�oding ; � � , . _ , prvmcnennts,nrr nnt in�cnded rrr nfJ<. cd(ar saf��. f/,
T_,^!t i � � � . . � . . bneeeuer,t�+e bri.ildin,q nr bq/rrove+uent r sold rrithm nne
Geolagiml . — T�ur o/rnmplatinn, tFin urnrtar-buildcr eriJ!�burr tbc�
�_ . . .. ' burJen nI.l�rurin,G tbul l�a•did nnt 7 riltd nr imJ�n>r e!or
Peacietrlen Prot�cnon � , . . the purpose ri/.tule/• . .
lFance)1Connpy) - � � � �._ �I.asownerof+htspro�er^y,omexclus�veiyconta,�c.
I
. Iiny wid�liCensecl mnuactors ta<cnctr��cr rho p�nl�'ct�Se�
Spacicrl InspecLoi+ - � � 7044�(f�<siness und Pro(esxioas C;ude: 'lhe Cnulrerenr'a
IConc)I,MasonrY)lWelding) � . I,icen.e�l,au�duvs nn(a�i�il1�-to utt numer�f prnJ�ert1'«�1 n
� - � huilds nr i�nprnre.s lle-reun,auet u-Ga-i'untroUs%ur.s.h
Loi�ro;ncrgF . _ . . � . Pr Jrr[s u�ith u confrdrtor/.v(leeen.�i-d far.vu�nt 7n'���bc
Crrnern.lnr:r I,i�anse fau/.
Pc>.k�ng � � _. I orn axempt unAer Sec._ .6$P.G(or ih��.s
reuson _
Dnre . . . Owoer ,_,.,.
� Rpprovalx pafa Inspenor's Siano4ure � . - � .
_�� �_� INSPEtiOR'S NOTES �
lr,ca���on- �
iSeiback&Yardsl '�-' ��� �V���� � � � �
ro�„d�,�on� —___ — �'`� ��"'1 �' ��� �_
s��h
F,��,P �r rd £s'7 � �fi��� _
Er��rgy insu�mion . y�,���� � � �
�- ��
I.n!h:Drywoll_. r/�� � ... ��
Inier _._..._. _._�_..._...,_� ....__ �� _ ... .�._
_'.... _.�.
Lalh-Exterior ����f �^7 }�J� .. .
l / /-vro
fiou5e!v��nY�sr.. ._ ........� ._.,., __,__ . - .._ __�._W_
� C:orrec+&Posrr,d �
f��,r�� � . . ,
Enrer en Fron� �� � .� _ ...�_____.___ .
� . �` . . . . � .�-.....� � .___ _ .--�---..
�_�....._.. '____-__'...�._..— '�..— � ..Y..: � � ,, � � ..� '.'.`�-'
. . '��—_�.�_ _