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HomeMy WebLinkAbout0768A .,. _ WORKERS'COMPENSA710NDECLARATION �- ° ' 1^� � '� � �� '. ` � hereby affirm ,�a, I have.o certificate ot consent to=e�F � � APPLICATID-N� F4R BUILDiNG PERMIT � � ����� i�sure,or a certificate of Workers'Compensation Insurance, or a certified copy thereo4(Sec.380D;lab.C.) CQUN7Y OF l05 ANGELE$ BUILDING AND SAFETY Poii�YNa3WC005-27�0���,� I�ationwide 1/A � Certi#iedcapy is hereby furnished. FOR APPLICANT TO FILL IN euaoiNc 626. Armitos Place A�ORESS � Certified copy is filed with�he county building�inspeo- ` � eUaoiNG 626 Armitos Plaee � . � �tion departmenC ADDRESS Date 7�/B/87 Applicant THE ANDEN GROUP �iTr Diamond Bar � Z�P 91765 '� ��i�� Diamond Bar � - CERTIFICRTE OF EXEMPTION FROM WORKERS'�`'� � - - � -� NO:OF BLDGS. � . NEAREST ���-. . .�. __ .. . . . � COMPENSATION INSURANCE � SIZE OF LOT NOW ON LOT caoss sr. amond 3Y� LVd. Golden 'n (TMs section need not be-completed if the permit is for one � � ASSESSOR � , � � - hundred dollars($100)or less.� � TRAC7 BLOCK LOT NO. hAqp BppK FAGE� 7ARCEL � -� TEL US ZONE N✓�7 I certify ihat in�he performance of the work for which this OWNeR THE�ANDEN� GROUP. No.967-9541 NO. � Il •• 3 ?, permit is issued,1 shall nof employ any person in any monner P,O..&ox�3329. _ �� . . .. "f SPECIAL � �� � - � - � a so as to 6ecome 5u6ject to the Workers'Compenwfion Laws. NDORESS QQd CONDI IONS :V `�'� n u�a�r a1r Covina ziP 91722 _. , . __ . _. . . � j rRCE TO APPLICANTiI� after making this Certifica�e o4 ARCHITECTOR � , TEL. _ .DISTRICi GROUP TYPE . . FIRE ROCESSED.BV . Q em tion, ou should become su6'ect la �fha Wo�kers' � ENGINEER NO CAc�NST� cZ���'rfqqJ�IIIfi�� N CompPensotion provisions of the tabor Code,yo�mos�fonh- A�aEu � 314 N. First Arcadia 1 �0 �'3 . ,y��- l`� . �d with comply with such provisions or Ihis�permi� sholl be TEL. STATISiIGAL C�ATION �� APT. NDO. Z deemed revoked. � CONreACToa THE ANDIN GROUP No. LICENSED CONTRACTORS DECLARATION-: � � � �� � ��i�. CLASS N0. � DWEii,�UNiTS� I hereby affirm that I am licensed under provisions of Chapter 9 ADDRE55 NO. �yyER MAP � (commencing with Section 7000)of Division 3 of tha Business and .. .. ._. . . ���, .. _ . ' ��� � Professions Code,and my license is.in full force and affect. CITv CLA55 B BK: � � � � . � VALIf1ATION- ��� � SQ.F7, NO.OF NO.OF CHECK , � � �� ' � ��ce�ae N�mber 510560 uc.Ciass `B srze 1535 STORIES 2 Fnreiues 1 oNe - THE ANDEN GROUP 7/8/87 oescziarioNOFwoeK Single Family New vAtuAnpN _ Contractor Date � ; 7 r$�9 ' ADD �I am exempl under Sea � -� - Gara e ' - O . ALTER `�,D 7�8 p B.&P.C.for this reawn � ... AB a Y . REPAIR ❑ s - . . �. .. . .. . . . _. . . .. . USE OF : hr• • • • • Dafei�� FJCISTING BLDG. DEMa -.. . . . . . � .� Signature � . .. .-. ... . . APPLPRIN7T TH ND ND. FINAL //f„y/8-p�' I �' •7�1.C� OWNER-BUILDER DECLARATION �-pATE � � �� � � - - I hereby affirm�hat 1 am exempt from the Contractor's Lkense � . e c u.j L',E,v�� /^�w{or the following-reason(Sedion 7031.5,Business and ADORE55 FINAL � � � � `euions CodeJ:. .. . . ___ ... . . . . . . R �Y - � . . �� � 7'�a 7 . �. , � BUILDING I, as owner of the properfy, or my employees with ADDRESS � . � � - � . . . . . .... .. �. . ' . . .. wages os thair sole compensation,will do the work ond , ' The strutture is nof intended or offered for wle(Section ��A��T� � ��' � � � -��� 7044,Bosiness and Profezsions CodeJr �- ' � mOwnlG - � � - TEL.� � - �� � � - � � - � � I,as owner of ihe property,am ezclusively Cpnlracfing CONTRACiOR NO. - .V, :-� �. � � with licensed contractors to conshuct the project(Seo- �A�E� -�� � � � � � - -�� � � - tion 704d,Business and Professions Code}. � . - � �� �- CONSTRUCTION LENDING AGENCY �� � SEi�QACK � YARD HWY �T�TApROP.AINE WIOTH � . I hereby affirm�hot ihero is a tonstruttion lending agenty for FRONT � � � --�he performance of ihe work for which this permit is iasued P.t.� - � �� � - -�� - (Sec.3097.Civ.C.). SIDE . . � Lender's Name.. . L'1C1b2111L . ._ . . . ... . P.L. .. . . _ . . , -.. �. � . � ' ' ' � P.C.Fee S ' �'- Permit Fee � 6 3.7 5 �DMA Ref.M , � - �e�der'sAddress 444 S. Flower. L.A. 90071 , w ,� .I cenify that I have rend this opplication and stafe Thm ihe . Isavancefea �-Q•50 . iDMA PiC M - - -- � � � �-� - ¢ above Informati is correct.I agree to comply with all CouMy Invesi�pa��oo Fea . �� g ordinpnces a tpfe laws relating to,building constructio�, . . . . - Towl Fce 7 4.25 � �LDMA Perm.M ' -'- ' '�� - ' ���' u and hereby orize rapreseMatives o4 this County to enter � upon ihe -m " roperty for inspection purpo s. , ¢ . � . � _ . ._ .. .. ^ SEE REYERSE FOR E%Pt�NATORY LANGUAGE .. . - Signa ure of pplimnt�or Agent ....- .. �e . - . . -. .. . . . .- .m ( ' PLANS TO APPLICAN7 iNSPECiOR'S�NOTES�� . OWNER-BU/LDER DECLARATION , . 1 here6y affirm thot I�am exempt from the Coniractor's To: �. RWvmod � � ' - . license�1aw�for�the following reason. (Sec. 7D31.5) � � '� � �� � Approvad BusirsessaxdProfessinnsGiderAmycityorcoewtywbich � ' No. �ota ' No.' ��� �. Data �� � � � � � - requires a p¢rnrit to co+utrr�ct,a(t¢r,ineproue.dernnlisb, or repair any slractr�re,pnor to its issubnce,dlsa reguires . � . � � , . .� tbe opplicant for swcbQernsit to�file.a signed statement that be is Jicensed pwrtuant to LbeQrovisions of the Co+r- � . . � ... .�. � � . tractor's Licettse Law(Cbapter 9J/commeRcipg witb Sen - _ �, - Eion 7000J of IJivisiox 3 aj tbe Besiaess and Projessions , � �.� �� :... .. , . -�. : ." .. -� -�CodeJ or ebat he u ex¢mpt t�ierefsom and tb¢basis for tbe . .. ..,_ . ._ . . . . ... . . � a!leged exemption.Any aiolatioro of Se�tion,70315 by . � � ' � Required � Dufe R�cdv�d � . . . � . . . .� �- °ny aPPlicantfara permit axbjectr the�epQfi�ant to a cevil Approvals � � or Approwd . penalty of not rnare tban jiue bµndred dollars(d500/.J: Yos No � - - , ' � - � � - � �� � ❑ I,os owner of the property,or my employees wi�h Wa�er Certificate � - _ . �. . . -- woges os�heir sole compensation,will do the work,and � : . � � .� , . . . .. .. . ,. - � - �--� � �� �� - � - . . - the�structure is not intended or offered Sor sale(Sec.7044j HeaHh DeportmeM . ._ ._. . _ � . � �- � - �. �� . � . Business oxd Pmjessions Code:Tbe Contrattor's License Law does noi apply to an owner of property wbo bui[d,t. - Fire DepartmeM'�. ._.� . . . . . � � - or imQroves tbereon,and who does sacb work bimsel� . .., , , � - �tbroagb�bis own enf�loyees, provided tbat��such�. � Gradin9 � �� , . ' . ' � �� � � provemenu are not intended or oJfered jor sale. , ' � � � � � �� bowever,tbe buildinq or imQrovesreenL is sold witbin one . Geological � �. , ��'-. ... . - .. . . - . .-��� �.. , year f�completion, ibe oumer.baslder wil!bave�Ebe .. � . _ � � - burden of�mving that he did not build or improve jnr Pedesirian�Vrotectican � � ��� � . � .. . the pssrpose nf sale/, � � (Fence)(Canopy) . . -� - � - � ' ' -- �� -� ❑ I,osowneroflheproperty,omexclusivelycontrac- ,. . � ring with licensed comracfo�s to ronstrucr rKe project(Sec. Speciof fnspectidn - - � � � � � �- � � 7044)Business¢nd Professions Code:Tbe Contraclor'a �Conc.)(Masonry)(Welding) � � � � � � • -- � License Lau�does nvt opply to an ownerofproperty who - � - � - � � - - buikls or improves�t5ereon,and whb contracts jor'sech Lot Drainage � � � . _ - __ . projects fuitb o contractos(s/licensed parsuant ao tbe � � Controctor'a Lic¢nse Lau�J. � � - �- Porking . . .. � . . ... . - . . _. _ . ,.. - � ' � ❑ I om exempt under Sec. ,B.&P.C.for ihis reason . . � Dote.. � . . . Owner Approva6 Dote Inspecfor's Signoture� . � � - � INSPECTOR'S NOTES � � Lomtion— (Se�back 8 Yards) 2 -... . . . . . .. . . . . Foundations . � � � Slab . . . . .� ... .. � . . . . .. .. Fmme � . . . . . . . : Energy Insulation . . . . .. . � . . . � � � � � Loth/Drywall— � . . . , � . . . Inlerior � � � � � � � � � Lath—Exterior . � . . �.. ...��... �. .. . � � . House Number-- - � -- - �-� - � - ��� - . . ' � . � Correc�&Pasted � � � Final— . .. .. .._ . . . . .. . .. __ . . . . Enter on Front � � � 1. . . . . . ., , *; �.,, � . . . ...r , .\` � y �`✓.",�> . . ��