HomeMy WebLinkAbout1755A 1756A WORKERS'COMPENSATION DECLARATION .. .. �
I hereby aFf�,m ihat I hove a certifica�e of consenl lo self APPLICATION FC�R BUILDING PERMIT
- insure,or a cerlificafe of Workers'Compensation Insuronta, .
or a certified co rthereof(Sec.3800,Lab.C.) �
�o�Wa�05-2�y—OOl�om��Y Nationwide 2/g CaUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cerrified copy is hereby fumished. FOR APPLICANT TO FILL IN 6UIlDING
QADORESS s Place
Certified copy is filed wiih the county buildin9 iq5pec- BLIICDING
��o�deporimenl. AppRE55 620 ArnlitAs P13Ce
Da�e 7-30-87 APPlicant T� �IN GROUP ciry Diamond Bar Z1P 91765 - ��,i,Tv D' nd Bar
CERTIFICATE OF E%EMPTION FROM WORKERS' NO.OF B�DGS. NEAREST
COMPENSATION INSURANCE SIZE OF lOT NOW ON LOT ceoss sr.Diamond Bar BZVC� & CaO1C�{2S7 Springs
(This section need no�be complered if the pe�mit is for one TRAQ 42579 gip�K LOT NO.z6 �ESSOR .
hundred dollars($100)or�es5.) NWP BO�K PAGE PARC�L
TE�' U5E ZONE hV+P
i certify Ihat in Ihe performance of the work for which this OWNER Np, — p`' � � _'3L.�
permit is iss�ed,I sholl nal emplay any peraon in any manner qDDRE55 p.�• BOX 3329 p�� SPECIAI O
so as to become aubjeci to fhe Workeri Compenwtion Lows. Da� CONDITIONS
arr Covina z�v 91722 v
;'��•te Applicant d'
ARCHITECT OR TEL.
JTICE TO APPLICANT: If, after making�this Certificate of ENGINEER �Ve $ZdIl AIA No.445-4073 DISTRICT GROUP TYPE FIRE PROCESSEDBY O
Exemption, yau should become eubjecf to Ihe Workers' �O �� GONST. 20NE U
Compansorion provisions of the Labor Code,you must forth• qDp��S 314 N. F'1TSt.� Arcadia 91006 N � mq,dne Ly
wiih comply with such provisions or ihis permit shall be TEi 0•
deemed revoked. SrqnSnCnt CV+SSiFlc,4iioN AP7. CONDO. tA
CONTRACTOR NO. }1
LICENSED CONTRACTORS DECLARATION ���. a.455 NO. OQ DWFLL,UNITS� Z
I hereby affirm that I am licensed under provisions of Chaptar 9 � MDRE55 AS c"l�OVO �510560
(commencing with Section 7W0)of Division 3 af the Business and ��� SEWER MAP
Professions Code,ond my litense is in full force and effact. CITY QASS B VALIDATIQN
Sq.iT. NO OF NO.Of CHECK BK' �''
liCense NumbBr 510560 Lit.Class B SRE 1314 STORIES 1 iAMILIES 1 ONF �
Controcror THE ANDIN GROUP 7-30-67 OESCRIP710N OF WORK $111 le famil NEW YALUATION `.� .7�5 A
oate s 6 8�2�0
ADD
❑I om exempt under Sec. F �° •a `2�
ALiER
6.8P.C.for this rePson REPAIR � s (; ?.;� � •2 J�,8 4
USE OF DEMOL • . �� i
Date: E%ISTING BLDG. �
�-,%:�,4�
Signature APGLICANT iE�. FINAI e , .
OWNER•BUILDER DECIARATION PRINT NO, DATE �' �/� O�'� 6—$7
I hereby offirm thot I am exampt from the CoMrac�or's Licanas � AS a170V2
Low fo�ihe following reason(Section 7031.5,Businesa and Aooaess FINAL ,,,//
�'`ofessions Code): 6y /�r/�
� BUIIDING
I, aa owner of the property, or my employees with ADWtE55 a
wages as fheir sale compensation,will do fhe work and � 2r 1 7 5.6
�he atrudure is not in�ended or offered for sale($ection ��'0'��T�
7044,Bvsiness and Professions Code). MDYING TEI. �r o • • . .�
� 1,as owner of the property,om exclusively tonfrocting CONTRACTOR NO.
with licensed con�rocton to construct�he projecr(Sec- qpppE55 � �''��?'�0
lion 7044,Business and Professions Code}.
CONSTRUCTION IENDING AGENCY REQUIRED yqRD HWY TOTAL SETBACK c °�J I C,G U�
SEf BACK PROP.UNE WIpTH -
I hereby affirm thpl there is a constructian landing agency for FRONT 0°.1 6�8 7
Ihe performance of ihe work for which this permit is issued P,L,
($e<.3097,Civ.C.J. SIDE
L'1t1.IJc1T1�C P"�.
Lendai's Name �
444 S. Flc�wer, L.A. 90071 RG Fae 5 Z 3 3.84 r P„m;,F� 3 fi 1.5 0 .� �DMA Ref,k
m lender's Address - ,
� I certify that I hove road this application and stale thct the �ssuance fee �-0•5 d L�N✓a aiC M
abava informotio ' Correcf.1 agree to comply with all County Invesriqmlon Fee .
$ a�dinances a e lows relating to 6uilding conatrucrion, To�al Fes 372.OO �. IDMA Perm.#
and hereb u rize ropreseMativen of ihis Coumy to enter
� upo th oned property for inspection purposes. �
m � fEE REYfRSE FOR EX►IANATORY LANGUAGE
Slpaaeura of Appliwni or AQent pp�e . ,
PlRNS TO APPEICAN7 INSPECTOR'S NOTES _ _ UN'�IiN-RlH(,1)k�.N DF;('.LAR.41YU,v �
I FPreby uffirm lhot I nrc�.cxea•.pi from+hc CoriNannr's
�To: � Raturned � . .i � ti _�w Fur �4.e follo � ,g r..,�r. (Sec. �p?i 5
_ APPraved — _____�_�.._.._ L3u.yirtes.s�and Yrr f��s�innc Cnde;/lrsy rrtY n :uuntl�rrhi:L
�.Wo. Da4e No. �Dato . . re�qu�ires a pernrit lm m�struCt,.<fter n:prvirq.dcra��lisfti
��
_ __ ...____— .._____ .._.-__ __...__ ._ ___ no r p r.lr <i pr t t.. .s .t /.� ��r� c
. . � - . � . . . fh /p! r I -�1 p,. �e r /f. r 1.e r t
- �— --- -- --- tbul/� st:�nud/ r� �itt 11 p,r� ¢11 C'+
- t-
���� - . � . � � trr!»s l,aen l,a e(C;1�,�pN )//�u� �ncen.q u it! 5ca-
� - - — -- — — r;,,� -oou�<,f� � 3 ��E cr ti<„ � �i >> .r,..�<
��_��W. , . . C��dc)ot tbdt 1<<x'a�rrm/�t t/ r/r�> r +�d i/�.tinsi_/.r rbe
. �- alf�q d �.rr�n�pl��n Anv r !ti nJ V t e'0�1 5 hr
., . Requir¢d � Dafa Rseoived � un� (�rlicuttt.l Oerrnit euh�c�ts flre ipJl��an(t vril
Approrals �� No or Approved ` . f'nna11F n�nnt mon tfiar��n�I�undr d d]lars(�5(/lll:/,
—__ .. ..__-#..,�....�._. � �... I,as owner of�he n nrt ry m cm lo� r{�
--- . _ ___` -=. �_ _._.�_.__. F� n v, v � �P�.�w�
l��ier �.I.f i.u�e , ' . . :� �, � . . . w-ges os rhe� sNe comp �ai on.�n II I. iV e wo�b,a��d
�_. .�, � � . �- the shuUure Is nrn intended or o�Fe�4d fo si�le(Se,. 70A1;
Heni n Depa.men+ � � - � - � �� � . . Uusincsc..nd I r ifr s 1�C f� I!c( t.t t r 1 :.n v
l.au d � [upplv r an n� f Pr p. tc i 1 ! !d�
°�•e pePn.im=rr�_—'}�_�.� —_ � . . . . . "�.-".� � � or i j s t!- .and�! J -. � ¢ r rb 6� w!L"
� . . � . . .11rruu,¢d> kis a.n ��npfr�l�e,c, Jrror•iAcd tGut su.l z.
n tnq . : (1 � prne�emenh nre not ixtcnd d ¢(<�rvd li>r snle 1J.
�.._'� �. .-'r ' .. ' . .. . � bnu e�,cr,the 5ri.ilJin,y nr un)m u+�ent iv ea1J u ithin nne:
�n,loylcal . . .. . . Ve¢ �eomp!Ei in. the u n�r.br�ifder xrall bn �� t!e
_ . . . . . . . 1 u Jcn �(Jrrr i ii,� �hrzl l.d J nnt haild nr im(�r r�for
�Pc+rc lwsaiun Rrcrle�E+iun . '.. •� � . . , . M� p�rpr.rc n( alr). . � � � .
,F�nc<,I:Conopy� ..I . . .. .. � � .. I.usewnr,rnftheprqperty,urne cl,:��ee�lyronns:r.�
_ _� —' — � ting wrth hcensed cp�+tracto�s io<onsrrucl ihe pro�ect(5�c
Spc�c�al Inspecrron � '
� 7D4d1 Busine.9c und Prn/e.esrous Cnd<�� 7'hc Cortlrurenr:e
�Co��c S iMosonry)IWeldina} . . . � Lr�ense l,um ducs nnt uppll'h�Wii r,uvt�v uj prnpertv u�bn
_____. FurlJs nr imprares lhereon,.vid�ol�n cnntr�ru/r+r srorb
�et D�aina:tc � . - ". . /ir<jrrts u�r`th a cnmfructnr(,cl lrmensod pursu�ut tn tGr
� ' ' � Cnnrra<rnr'c t,icenxe I,uuJ..
Pa�k�ng . ,� I om r.xempi under Sec.�_.f3.kP.::.for�h�s
- . � � ' - recson �
� Ooi� wner ._
Approvals Dcta Inspeclor's Signulws � �� � �� . �
�-�._�—:'_�.�_____� It15PEfTOR'S IVOTES
(Seii}ack�8 Yards) I ��f��j,p�-. �//����y � .
Fou•�dations � � - � . � �
SIaL — . � . .. - ' � �
Frarne �� /�}�-f �� . . � . . .�
. ._ �._._ .� . .�_
E'�erUY I sulation �� ! �� �a��y:.� . _. . _ . . . �.. �� . ' ..
L tfi:D.ywalL... /�Ai 3 �� If R/ ,�j . . . . . . . . � _� .
Inte.��U� �
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Lorh-Ex�er�or /��.� �) ' _ ...
Ncuse Numbe.._. . .�. . . .. . . .., . _.�
Correet R Posted � � �
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