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HomeMy WebLinkAbout1717A 1718A WORKERS'COMPENSATION�ECLARATION . ti J� . insure,borafcertifco'ieofWorkarsrrCompensationensvrancef APPLICATION FOR BUILDING PERMIT or o cerfified co thereof(Sec 3800,Lab.C.) � �� ��Wc�05-2'��-001� Nationwide COUNTY OF LOS ANGELES BUIIDING AND SAFETY o icy o, ompany � Cenffied mpy is he�eby furn�shed. FOR APPLICANT TO FILI IN BUIIpMG ano�aess __�.._._.._ . ace Ceriified ropy is 4iled with�he co�My building inspec- BUiIDiNG tion deparrment AooRE55 624 Armitos Place Date 7_30—$� APPIicaM �� �D�7 �UP CITY D1d[OOT1C7 BdL' Z�p 91765 �OCnLITY Dl BdT' CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF eLDGS. NEAREST Diamond Bar Blvd & Golden Cf COMPENSATION INSURANCE SIZE OP LOT NOW ON LOT CROSS ST. S�lT1I1 S (This secfion need nof be completed if the permit is for ane TQAR 42579 g��K l07 NO.27 �ESSOR hundred dollars($100)or less.) MAP BOOK PAGE PARCEL TEL. USE ZONE �7 I certify that in�he performance of�he work for which this OWNER NO. ^ !' NO. /� 3 1-� permit is issued,1 shall not employ any person in any manner qDDRE55 T� SPECIAL �, so as lo become subject to the Workers'Compensmion lawa. d0 COrvDiTiONS � U f^'��te Applicant dTv ZIP � ARCHI?EC7 OR TEL. . JTICE i0 APPUGANT: If, after making�this Certifitate of ENGINEER �, _ DISiRiCT 6apUP ttPE FIRE PROCE$SEDBY Exemption, you ahould become aubject to the Workers' CONST. �ZONE �('y� 1— Compenwtion provisions of�he Labor Code,you most forth- �3 � y�. 1'I t�n U wilh comply with such provisions or fhis permif shall be ADORE55 ��. STATISTICAL QASSIFICATION APT. CONDO.� a deemed ravoked. N CONTRACTOR NO. M�,` LICENSED CONTRACTORS DECIARATION ���, CLA55 NO.�DWELL.11N1T5�� Z I hereby affirm tha�I am licensed under provisions of Chapler 9 ADDRESS AS d}JOV2 nro.510560 (commencing with Section 7000)of Division 3 af fhe 6usinass and ��� SFWER MAP Professions Code,and my licanse is in full force and effect. CITY CLnSS BK � VAUDATION 50.FT. ND.OF NO.OF CHECK Litense Number 510560 Lic.Claas B 512E 1409 STORIES], FAMILtES 1 NE � py VALUATION DESCRIP710N OF WORK NEW 14I s 7 Z�H OO - Contractor_T�IE ANDEN GROUP Daie 7-30-87 noo , �I om exempl under Sec. ALTER � 8.&P.C.for�hisyreason REPAIR s C.�� , � �� �1 7 1,7 A USE OF � Date: E%ISTING BLDG. DEMOI �• • • �'2� Signoture APPLICANT Te�. FINAL I •�4�J.5 5 OWNER-BUILDER DECLARATION PRIM NO. DATE �/�'/� I hereby affvm thot I am ezempt from rhe Contractar'a License � z law for fhe following raoson($ection 7031.5, Business and ADDRE55 �1S EibOV2 Flqp� • °���1.F 5 0 �'ofessions Cade): � Sy JBl11LDING 0 9,1 6-8 7 I, as Owner of fhe p�operly, or my employees with qDDRE55 wages as their sole compensation,will do rhe work ond , tha structu�e is nof in�ended or offered far sale(Section IOCnLiTv 7044,Business and Rofessions Code). vnOViNG � � TEL. � I,os owner of the property,om exclusively contracting CONTRACIOR NO. wifh litensed confractors to construct Ihe projecf(Sat- qppRE55 ��7 7 1,8 A tion 7044,8�siness and P�ofessfons CodeJ. CONSTRUCTIONLENDINGAGENCY SEi�BACK YARD HWY TaTApR�AINE WIDTH J�e a � e f � , 1 hereby affirm thot there is a construction landing agency for FRONi ihe performance of the work for which this permi�is issoed P.�. � 1 m 3 9 0.0 0 (Sea 3097,Civ.C.). SIDE � Lender's Nama Cltl}JaII}C P� �4�1 6��8 7� LendeisAddres!}44 S. F1oWeT� L.A. 90071 P��•fee5 244.55f ve�mi+Fea 379'.SO .f ��'Ref.N �� I eertify thm I e read this oppliemion ond atate ihet the � ies�a�ce cse I Q�. ��mta ciC� � '. obove inform is corroct.I agree to comply wiih oll Counry Invasriqarion Fee � ordinancas n State laws ralating�o building conseruction, To�al Pae '390'Q� IDMq perm.N I and her y t nze represenfatives of this Counry to enrer u n r e�w�yp_' e�d prop�e.r=for inspec�s� DMA — 75.00 �35.00 v G/( SEE REVfRSE!9p EX�LANATORY IANGUA6E Signature of Applicanl or Apem Dote � FIANS TO APPLICANT INSPECTOR'S NOTES ,- . D��'�EH-IiCi11,OP:R Ut.I:I.AN:1�PlOti- � I her,,,b�.ofs�,r.��hm I a sxc�npi{rom thu�Cornrccic,�s To: � Raturnod . �- Gccnse Law f�r rhe Follow;na e�_�s.n. �Sec 70�� 5y Approved Hu.ciueas rend Prnh�ssiuns CaJa�::in4 citT nr:nuntv u�bi:6 Mo. Da/e^ No. Dofe ' � rcyuires u pern+it to r�rs�n.ct,�l4rr,.inr/,rr�rr.dr�nn/ish, i _..--_.,_._.__.___ ..._ ..___ ..__-.___- _---_....—.�: .—.—. �if r�.(+i[irunv'fr�['[r�rV��'rr� trr rtk u.Sr�Unet�uler�rPyiaire•.�� - - - . rbF„ppGcanr jor:a.h pe,ri�le ro!;[r�n s1,�n��d se,�remen� __ :�...:.__:� � � �.:� � ---- tbat be�Rs li�ens��d pvrsu.�na tn tA,e prurisiuns u/the Coa- � . . . �- . � trn�Ynr'e l.ieonsr l,au•�Cl���fcr)I/co nrin,G u�ith,lec- .�,.�.. . _-,_._.. _ _ ,— rion 7UOU)a7 Uicicion i n/thc B«sin�e�and/'r„l��vs�ons .. � . . � • . CoJcl�>i thu[He is�•xen�pt tGrre/roni und�!>c hn.ai.c/ur ebe � alleged axen��rfinn.Anv�,iuloainn��.lertion 7f1i1.5 bv . . . Requirod DateRsteived ar�1'�/�/�li�unf/�r�ipermite�uhjcat.eflre«pp/rc�n�lo¢:eri! Approvals or Approvad . pena(!Y n/nnf mnrc tbau firr h:enrlreJ d��llar��(!+5f1U1.J' Yas Na �..�._,..�..-:,___,_ . � (...� I,�s ownnr o!the property,o�my employee^:w�7h Wo1r.r C:�:�nrfr,zne . �I�.'� � ' � , , . - . . wogr.s os�heh snle compenxnrion,wJ��,do ihe worM,nnN �, . the slruclure is not intended or offercd fo�saio;Sec: 70-41 Heobh Depar.rc�eni - � �---' Bus�ness and Prn(essioas CoJe:7'hn(';nntr,�rtor'cl,icense �____._�._ Luu�dqns nnt ap/+1��fn un oianor n/rroperh�irE�n huilds Fire�aporrm�ni . - . � or iisj rnr,a•s thrrcun,und ir!o duvs s�a�h xnork binisu!/" - ._.. � . . . - tbrnu,�b b;e� nie�n crnplql�res, prurrdrJ rlat su�,7� i G•oding � �� . - hrov��me»fs nrn nnt intanded �s� u/�ered /ur aala. ll, � _ . ` . � . � . . ,. . bmoercr,tfie br4ildinH nr irap.nnenient is anld�riEl in nne Cenl��l<al � � . . . Y�'ur oj�cnnrp/etinn, thr �u,ner.Arsilder ari(! Lrare thc __._� . . , lurden��J prouing thol l.e�did n=if huild nr rmprnrr Jnr 'nei�ntriew P�aMe:�en � . !hr purporc aI sutr/, � �Far�ual IConopY) . . . [; I,os owner uf Iho property,om excl�s,�a�- y cn� � , tinG w�ih license�d ccniraclurs Io cans'rue�the p�o�ec�!�Sac. 1 Spec� I I spauic� � . ... . . . 70n4!/ir.�n.. J P njvc . (, J 1! ( nt� �t . (C.on .:�Nasonrvl(Welding) 1.0 n..I i d<�n �.e(�i� u. rf Jh Pc tt -1� hurl�h rr rn� i �s Kue n rnd u l�r �on�r�c�a fnr.��b . �lor�rnma9a . . . . . . . .. hn jee.rs u�itb u�nnrrycrnr(s/ttrcnsrJ pvrn�,rsr [n�rGr �� Cnnern.-tnr?l,icenx�-I.au�J. Parkinq . � r...-I - . ._. Iumexempiundor5ec. ,B.NP.C.fo�ihis reosori � . Dqie. . � Owner � Approaals pota Inapecfor's SignaOare � � ,� , . . 1lESFELTOR'S NOTfS �..�____._. �... �.� - .aca.�on- / T/ ��+�, . ISeIl,or4&Yordsl _.._._ _.�,.� ..�'�J ��" �p '�+.�� ��"1' .. . . . . �-�jo- Poundc tlons � �// � � Slob — _ ._ ._. _ . _ ___- =,�mF B/ !�7 �..�. ----- Ene•4Y Insulalion '� ,�, '... . . ., . � �. . .__. _..__�.._-,.-_ ....-.�.__-�. .�-.-...-.�................T._...,-..�..--__^-_-^ Lath;Drywall- �3 y1 - �nferior � �/ �.� � . lnrh�_Eatrr e' �e;� �°�"? ��y�p�,�� � .... . ... . .' .. . .�_ ' �'2..:_'____- " ` ' . NC.'L:St'NUThP/.... f� ."�'_ . . . . '..-._�.....,_.._�_ .�'�.�..._�_ COIf2Cl B FOSie(j � Flrol. '— . . . . . - En� �i Fronl � � � � .. s , ; ._ , - � __.':.—:._._.T..._.._..�.�.._._..:--^+LL.�—.'-_ . . `�` '�� ' _ ' . .r �.�.-...L—_.._�_._._. _._._ v..__. . . .----._