HomeMy WebLinkAbout0820A WOQKERS'COMPENSATION DECLARATION � � J"�
I hereby affirmjha� I have c certifimre of�o�=e�„o Se�{ APPLICATION FOR BUILDING PERMIT
insure,or a certificate af Workeri Compensotion insurance, ��
or a cerufied copy ihereof(Sec.3800,Lab.C.) COUNTY�F LOS ANGELES BUILDING AND SAFETY
7�o�C�05-279-0(�mpony Nationwide 3��
� certified copy is heraby f�rnished. FOR APPLICANT TO Flll IN BUILDING
ADDRESS 1'tOS Place
� Certified copy is filed with the county building inspec- BUi�DInIG 663 Armitos PlaCe
lion deportment. ADDRE55
ua�e 8/5/87 ApplimM THE ANDEN GROUP aTvDiamond Bar z�P91765 �ov,urrDiamond Bar
CERTIFICATE Of E7(EMPTION FROM WORKERS' SIZE OF LOT NOW ON OT GROSSSST.DlaIT1011C1 sar BZVCl & Golden $ 111 S
COMPENSATION INSURANCE p g
(This section need not be compleled if the permil is for one TRAC7 4�L S H O BLOCK LOi NO. 16 �ESSOR
hundred dollars(5100)ar less.) 1.1F+P BOOK PAGE PARCEI
��' USE�ONE PMF y
I certify that�in the parformonce of the work for which this OwnIER NO - �/ NO. II (��
permit is issued,I shall not employ any peraon in any manner qDDRE55 P•Q•B�X 3 3 2 9 '`� �ECIAL O
sa as to become subject to fhe Workers'Compensotion Laws. g0 CONDI7iON5
Covina z,P 91722 v
�:r"e Applimnt A CHITEQOt� TEI. �
t� .c�TICE TO APPLICANT; If, offer making-this CerHfitafe of ENGiNEER UdV� Szan AIA No.445-4073 DISTRICf GROUP CnONST. ZONE PROCESSED BY 0
^�Exemption, you should become subjec� to Ihe Workers' V
� Compensation provisions of�he Labor Code,you must forth- qDORE55 314 N. First, Arcadia �a W
wf�h comply with svch provisions or �his permit shall be (y,
deemed ravoked. TE�� STATISTICAI CLASSIFICATION APT. NDO. z
CONTRACTOR O. A -
LICENSED CONTRACiORS DECLARATION �i�, M55 NO. °G'� OWELL.UNITS
i hcrehy affirm tha�I am licensed under provisions of Chapter 9 ADD2E55 �1S above No 510 5 6 0
(commencing with Saction 7000)of Division 3 of the Business and ��� SEWER MAP
Professions Coda,and my license is in full force and effect. CiTY M55 B BK � VALIDATION
50.FT. NO OF NO.OF CHECK �
License Numbar 51 D 5 6 0 t�c.elass B size 14 0 9 STORIES 1 FAMILIES 1 ONE
VALUATION
co��ro�o.THE ANDEN GROU�fe 8/5/8 7 �ESCRIPiION OF WORK NEw
noo s 7 280 ,
❑I am exempt under Sea GdY'd e 46 2 $F ,^0 8 2 6 A
ALTER
B.BP.C.for�his reason SLAB ONLY REPAIR � �• • • • •�
Date: VSE OF ���
- . EXISTING BLDG. I ��•7 4,2 5
Signature � APPLIG4NT TE�� FINAL
OWNER-BUILDER DECLARATION vRIM DATE l( �3/�- ° � 8 7 q,2 5�
I here6y affirm thot I em exempf from the Contraclor's License AS above
�,Law for ihe following reason(Section 7031.5,Business and AooaE55 FINAL ! �/� ��� ']-a']
, �fesslons Code): � !y ��iF�-''�>
� � BUILDING .
I, as owner of ihe properly, or my employees with ADDRESS
ages as their sole compensation,wil�do the work and ' �. � � , �
tha atructure is nat inlended or offered for sale(Section IOCnUTY � �
7044,Bosiness ond Professione Code). MOVING ' TEL. �
� I,os owne�of fhe properfy,am exclusivaly conhacting NTRACTOR NO.
with licensed confrvcfors to construcl Ihe project(Sec- qDDRE55
tion 7Q44,Buainess and Profesnlons Code).
CONSTRUCTION LENDING AGENCY SET�&4CK �ARD IiWY 70TAPROP L�NE WiDTN
I hereby affirm thaf there ia a eonatrue�ion lending ageney for FRONT
the performance of the work for which Ihis permit ia issued P.�.
(See,3097,Civ.C.}. SIDE
P.L
Lender's Name—Clt.lbank
LDMA Ref.M
$ �enda:so.dd.ess 444 S. F1owEr. L.A. 90071 P�F°°t PermitFee 63.75 ,
� I certify Ihat I have read Ihis applicotion and state that the - Issuance Fae 1�•5� �pMA p/C M
above infor is torrect.I ogree to comply wilh ell County ���astipa�ion Fee
$ ordinances d �a�e laws rclating�a building consiruction, Towl F�m 74.25 t�MA Perm.k
& and here o rize representatives of thia Couny fo enter
� upo ih e- ' ad propeny for inspection purposas.
� ����MI/6 7 .
m ��J/n/ fEE IEVERSE FOR EX�UNATORY IANCUA6E
Signarore of Applicon�or Agam tl1e . ----_.-.__._.
�_�.r�
PIAFdS TO APP4ICANT INSPECTOR'S NOTfS OS4'11-:H-RU7L1)1-:H llFi(�.C.AI{A�,IU\
C- f I f f ..�. f �.� t - �'�
i To: ' I RWfrnrd� I . ' _.— . .—_ . t L� t k c. f._ I ... �n l5ec, �'41 5�
r ,
_�_. . �. __ APProved f3 � c anrtl r �Juns(nA� Iny�rt
��C�ln. D te �No�T C1u9e ' ' .. . ' �� " n r,r s u r�t! � l nr.�un7ti �I[.L
_— i I .��. . 9 F � 1 u�t d� � imp i den f�!
._.._ ..._. .___.�-��..__—F— ._._--_.__ n j � r ci . p t :t.�xc�r . R r y .
�_ .�.._ � _ ._ I . . . t! uEjla:,e �( cl/ ��1 /rfr« tn J 1 t �t
��—.�., _ .. _I._ _____ � —. eJ at 1 s!r�n ¢) r� .� t r rk-p. /N (.
r.�I �_____._.�.—._ � ._" -- _— __ —_._..__ � tr t s 1 a ! um(�/ j I ))(r i< � n�reA��rN.S
- n flGll) f b t 1 ti�N . �. a d I / wnc
�`I .. i I � � . � � � � � . . � - . C.'dc/ il fLe . . �pii! jr di 1 1is/r1Gr
. . . .. _ 1' -- —.-- — a71 qed e�.ronrptv�,�rs.Anv ir lation �f 4<<t n ?(137.5 Ii�
.
Req r�d � DaT Recarved . . . . . � J>ti �pl,:ant j r j� t hJ �t.t{ fj� � t� r!
Ap9rava!s .---.�._ I!5 T nnt l! s I { 1 d rl 11 � 5 !)
Y� �t2r, I or Ppp o ed '—. 1' ( 11-
I .. . i #_�.:� . . . . . . _ .. , I.O I }� f F �� n ��rtJe� 7U,.",.
_.
.. _. ..,. � _ . . .._� w�q s ihe �. s >> I t �1
� — � —_ _ . th � . �_s er-`rj� o�(�.rd - .
�+..,-i* N �r.e�-� :-,-._._ � � . - �""�"— .i-- . H snu,suad7 ! .ao,roC�,J�.7h��( t r�r,l � x<
_�„_
'��.__. i , . � .
�:.,,___ .. .. � , :� - - � l.a��d�r�nor upplc rn,er l� P ru a�l ./ Y�.a
_.._--
ne � } �_. --_ - � ���.— oi� p . t1 � d f ! . l� ��1;f i � ,.
�-- _ ____ �... � . � N �C l�- . it�1 J i ulr/ t6+� tir h �
i � �.� F - . - . .--`-- .. pr [s� r� n t � r i l � (1 r d!r ul !.
� � .����.�.� . ( cr tl 2 !d �, aJ .. tis tl�ial r-+�
.._ —. . .,._ ,_ .�_ :' , . .
�< .- ,<, � ; ��� � -- ,<,�r J ��r: e� �,-n �rd ,u� �r.
a _ _.� �._� �� � -� � _ � n ,r rp � ,ti �r r r e,r �a r�r � f� �r,r
�F F Hci cr � I �� i . .. . ---_— � rl p r� .�.rr ir) . -.
i� _�"� �t-v� I � � . � . . � t I usc. o th:.�� Fr -�. rnc �I_�- �ly . .c
— — —�._._-_..T. —`". —" ti q w ti.�c c J c _. �� s t co- ' r t ,��i IS..
-��� ' 7D1n. Hr r�. id fr .v ( ,/ !7 ( �� �t rr
.,} I ..� , . . . . . . . �
c.� M ��ra! .Y 1-.gl� � � _ .� � � � . !. _1 d �n fdp/�I1f i r¢�n� l�prnpart2u..i
' __'�...,.__ __ _ _ . h u&1.> >�rrnpror e���thcre�n,ur.d�oC� �nx�racta 1r r.ui.Ti
�.. ._ _ .W .� � � .. . ..
l.��, .�� . �'� . _ . � . Jn� ts�nth u �rat �-t�.r(.il 4�rm��/purcredrtt ro tho
� ._ _.___.._..._— . � . . ' C.'� l nrt-r's�! r�n.r. 1.�..�). .
::r���� . _� ._� ... o�.i e. i.nds•r Sec .�3 3P.G fo.�h�s
..
.
`--...�' ----.- _. ._._..___ - ., . ... . �
�
� , . . � reason
„_—._._.....__..----.._._. . .
? .. . —. - _"_' Da�e Ow,,.F,. �
_.. . _�.... �_�
F.pp ovatx , � C�t�* I p ctor'z S�:.nct a � '� � .
.. ._. .___ IPFSPFCTDR"5 NOTES � � .—
. ._ __ �... :.._.�_ ___
tt y )
,
___��1��p1 r _��.- .-��__-
, _____.__ ___._____-
� �<< , __.�
i
� t
____ .__., _- � -- --
-----------� ___ __�__._'___---
� - - __.__- _----- --_-----�_.T_- _v
f .��__._.�.
�` � —�.�__—,___------
I — ---------__.�_
_--___���—..____._
�. _�;, ,:i.����, i ; _—�
-- ,__
� __� _. ----
r---; _.._. _ _. .. _--.- __---------.___-__:__.�_._...__�_.._
�---'---.__�.__- --- ____-._T
1 F:_E ... � � � . � � " . . . . .._..�.T.— ._»_.�
\ i
� --�_. _..__� .....—.._`__'____. � . .. . .
� i .N .. t . _ .. __—_'—_. ._ ._�.—. _.�_ _.. ....--_—...
—. �
'(c ._ ts F st:.-i �
— �_ � . � •
c �.._—.—_______ _____�_._ —_�_�_�—
` ------�---
I�-E -�c F ., { ...�.._.._ . � . � � .
- _..,.._ ,�.._ ..— _. —_—._. _._�.—._____
� � �
I�___ -- �--� -�-�__ , ,
,-_ _ __ �__ -- --
�____ ----_�___ ,
. -----�.