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HomeMy WebLinkAbout1622A 1623A (9) WORKERS'COMPENSATION DECLARATION - � �'7 I hereby offirm tho�I hove o certi(itate of�o�se�,,o self APPLICATION� FOR BUILDINC PERMIT � � � insure,or o certificote of Workeri Campensalion Insurance, or a certified mp,y thereof(Sec.3800,Lab.C.) � � �'� '�3F�C005-2/9-00�6 10/B COUNTY OF LOS ANGELES BUIL�ING ANO SAFETY Poicy o. ompanY�3t7nrna��jp � Ce�tifled copy is hereby furnished. FOR APPUCANT TO FILL IN qoo Ess 612 Bowcreek Drive � Ceriified copy is(iled with the tounty building inspeo- BuuDWG . tion depar�mene. no�Re55 ome 8-18-87 qpplicont THE ANDIN GROUP CITV D1a(f1011C�{ BciY' IIP 91765 iouurv Diatnond Bar CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BL�GS. . NEARES7 � COMPENSATION INSURANCE � SIZE OF LOT NOW ON LO7 CRO55 ST.(,"a io & Golden 5 rin S (This sectian need not be compleled if the permil is for one TRACT 42589 BIOCK LOT NO. �] M4G BO PAGE PARCEL hundred dollars(E1pp)ar less.) I certify that in the performonce of the work for which this owNeu TI� ANDIN GROUP No967-9541 use zoN� NOP �� _ ,F permir is issued,I shall not employ any person in any monner qooaESSP.�.BOX 3329 � d-4 �EGAI � �, so as to bemme subject io the Workers'Compensation Laws. COn7�inONS 0 U ,Aqte Applicont CITY ' 2IP � '. � l TICE i0 APPUCANT: If, ofter mokin �this Certifitafe of ARCHITECT OR TEL. DISTRICi GROUP TYPE FIRE PROCESSEO BY O 9 ENG�NfER Dave Szany AIA No.445-4073 coNST. z� v .amption, you should 6ecome subjecf io the Workeri ` Compensation provisions of the labor Code,you must forrh• qpppE55 F' adia 9 006 t V n'"� �� �' W with mmply with such provisions or thls permit shall be . � 0. deemed fevOked. . TEL SiAT15TICAL MSSIFICATION ( APT. CONDO. (/� LICENSED CON7RACTORS DECLARAT�ON WN7RnCfOR THE ANDIN GROUP i C: Z M55 NO. � DWEIL UNITS� I hereby aHirm that I am licensed under provisions of Chapler 9 ADDRE55 VE NO.�j]_� (� (tommencing witM Section 7000)oi Oivision 3 of�he 8usiness and ���, ��R�P � Professions Code,ond my license is in full force ond eHecf. - [tiv Cu55 BK � VAtIDATION � 50.FT. Np.OF NO.OF CHECK Litense Num6er 510560 t�c.Closs B � size 1440 sTORies FAMIUES 1 ONE � � VALUATION Co�rracror T� �IN GR�e 8-18-87 DESCRIPTIONOf WORK in 12 f1mi.1 "� � S 67,500 ' `� 6 2 2 A 4•�� SF, ADD , ❑I am eaempf under$ec. �{+ • • •G� ALTER B.BP.C.for thi�reasan REPAIR � f � - � •2 3 1.1 6 USE OF ❑ Dp1e' EXISTING BL�G. �E�� - ° �2 J 1.1 G c=.� APPIICANT ' TEL.� Signoture FINAI ,�/ OWNER•BUILDER DECIARATION vRIN7 NO. DATE '� 9 3V O 9,� � '�H I I hereby affirm ihot I am exempf(rom the Conimctor's Litensa - j�S dbOV2 law for the following reason(Section 7031.5, Business and ADDRE55 FINAL�� � � �.ap�rofeuions Coda): - � - � 8Y� �'"'� / � - BUILDING I I, as owner of the properfy, or my employaes with ADDRE55 wagei as their soie tompensotion,will do the work ond � i���Tv the atrvcture Is not intended or offered for sale(Section �� � � � 7044,Business ond Professions Cade). � MOViNG �� 7Et. � . . . � �=� 6 2'J A � I,as owner of Ihe property,om erclusively conVacfing CONTRACiOR NO. ! �• e . o .�1 with licensed contractors to construcl�he project(Sec-� qpoREu � � - � tion 7044,Business ond Professions CodeJ. - CONSTRUCTION LENDING AGENCY � ��gq�K YARO HWY TOTAPROTP IINE WiDTH � � � - � '3 9 9•0 0 I hereby affirm that there is a construction lending agency for FRONT . . .. • •3 o q,C 0 c=i - ihe performonte o/fhe work for which Ihis permit is issued . P.t. � . (Sec.3097.Civ.C.). sioE . .Q 0,� � �8'� v.t. lender's Name Clt1�]dIlk � 444 S Flower, L.A. 90017 LDMA Rel.M . Lender's Address P.C.Fee S Psrmit Fee 3$$.5Q � I cenify thaf 1 have read ihis applicaiion ond stota that tha isa�onca Fse LDMA P/C N obove informmi is correct.1 ogrea to comply with all Coun�y inrev�ganon fea . ordinances rate laws ralaiing ro building constructlon, To�ai F•. lDM4 vam.N � ond here6 ize r presentatives of ihis Coumy�o emer �pon v roperty for Inspection p�rpoess. n '� SEE REVERSE FOR EX�LANATORY LANGUAGE . � . Siqnature of App icont o�Aqe�r �e � - - '� .. .-Uti"�\IJ2-I3tI1i.i11�.It Ut:Ct.AKA ftUN FlAD;S TO APPLICAN7 INSPECTOR'S NOTES • I he.rr6y afh�m�b.n' I nm cxrc..p�Irom Ii�r.Crd.o;ir.•'s . To: . . , � . Returned , ' '� ' . . . . . L cense��Ln -'!o. ihm i Ilo�a�n9 �Sec.��70J�:7 � Approved f)i c nJl'rrf,srinn�('ndr::ln�utt'rnn;�unfou�/�i.b " No. Dote t�o. ' '�Doic .. .. ' . ' . . ��'.r .. ..�. . . : �� reyu�h c u prrrrtit tn ir n�lruil:uRr�,'iri�pru .drrnr:li�h. � � rr _ .__�__.—�_—_..__._. _._-_...___.__.___,____ .. . _.__�,rre(���i:dnV<irN�turi•.frir,rl.��irt'r.���rri..�rl..�rrr�fuirr� '.i.. - j�� �. . ' . . . . 1br✓pflr.,�nt�nr vnh frrmrl ln/�lr.a srprrrd sldfenrrnl i, . r ._. . __.. _ . ._' ' " . '_�.' . __._.�. ._ ' __ . '_- ___..__.. ._ . ._ .' .._ _... .. _ , � tl�o�hc r.v(iacn�rJpun«Jut tn tl�r prnri.siuns u/11�. Cnn- : r..,,;_ .. .�. . ��.�_.. . tru.lnr'cl.irvnsild�r(C/w�>ler7J/ mui ,xrirl.5u�- �.. . . ... _... ._. ._.._ _. .. .. . . . ... �i,rri � cinC _ . _ .. __'_ _. - _. _ _' ' '..�_ ..... _ . �. . . '- <.�,-:� �'��_' .' � :' ..,I �_ . _ :Cu�lrl�,rU)n/Di��ci,�n 3 l d U�. 1 Pr,�/,-��l.�nc U( -_ '--. .- - -. __._ .. -- tl�etb�•��vnii�rptthcreJn�.iranJib�br��ie/„rthe .. -_ . .._ �dfe,erd.exrmp�inn.Am�•��iularinn nf.le�riwr 7(�3f.5 h�� , '�..� . � ,Raquiiod , :. �. � `.� ".. _. _ .' �_, . _ ...._.. . ..__ .�:�_' . anYa pli.unt/nraparnritruLj�c�v7l�ea hwnttn�.ir7 � Dmo Receivnd � P . Ph � ApProvals , or Approved . . .— . . ' .penullP�4 nnt mnre lfion/nr hirndrrd d„Jlnn(�5001/' ' Yes.. No. - � . - . .. .�. . ._.. � __.. �_ �. ,_..... . _. �. � . �. . .�_.... . . � . .._ : . ' ..�.^.. ,-,i.., . � .. I...�' I,os owner o4 the F:r,p�ny.p•my emplo�. .�+��n'� . t1�r.Cen�l,ca�e .'. � �.. __. � ___ .. � . . _._ . . -- . __. ._ .. _..�_'..__... wages ps.�helr solc mmpeeso��on �tiJl c!�th��vo��.and . '� . thc si�uc�u�e is noi inienued o�oFle•ed ie�sule�Se.c 704.;� � � .:....... .. . .. , . � Hen�in Dapnnrnen� . _.. _ ''� ':��-�.. �'.. �.' � - ._.... -. .. ._.____. _'__ . .� __'. . . :, fi:uinrea unJ Pr.�/c�sior�r CnJr:7'6e Cnntr,i,�.irl f.i.rnsr . _ . - . � . .. - . l.a�o Jnvs nnt�pph�!.�an u�rnrr nJ prnfer/v�rhn Fui[J� .. ,-.,--i. -�.� F.r Dev�.�,�on� _ . . .__ ... _ . .._... , � . . ur _ ..- . ,. . prnr. r! ,n,�,nJ e 1,��do�� J f!' <cl(,� . -"+� . , . , � �1/r ,�l.�.�l . n:.rrnplo���. :p,n�lcd tb�rt�su,�l� , C,��,,,q � - � �. � . �., ' frnrurrenit arr nat ivfrnJ�d ur�o//rred Jnr snlr-. - � . .�'l . � . �-`/�nu e�er.thv bvildinA nr irnprnrrrnrnl rc vdJ�e•itbrn nri< � C �Icq�ccii. . . ; .. .,,.. .- - .. . 1 �dro r>/mr/�lin,Nu��I.�nv n�r.Fr:�i(Jer iri17 1. � t!. , � .. . ..� - ___ ' _ � . prr� ,� Jidn.�rl���ilJ�nr�� :pr„r�r/nr .. -, ---. .__. �.. _ . . . .. tr,�pnrJ�o ;iI rnL./, ; � � . - ,.._- - - . .. . - . Fcdasvron Pro�e�tmn .-.- ..- .' �. " ' ,.. .. . . . ,. . � " . rfrnce)IConoPYl ,. . ...� � . . ._ . ����� . __... ... �..�. . � �..... .-.�. .. • � .,,.L.; .I.os owncr af thr proper�y,am c..l�.s�vrly mn•.oc •Ilnq w�tf�i liccnsed cpnvncro�s in.<o�slru��thr pro;ecr(Sec ,� � , � . f�,......�.. .. . ..... _ .__. .. . _ �.. 70e41 fSr�siriesa��nd Yrnfracrnos(udr•'!'!�c Canlraatnr'c S�cc�1 Insprct�on' . '..:' . � . - . .' � � �. . .. I.�. c.)Ih^asonry)4Vleld�ngl . . . ... _.i ..__ __ �_.. . . . . . . �. _.:. ._ I�crnsi�L��rJnCS MM1I dJ�pl�'fo an.��u�nrr�J�+rnj,rrte u�bn FuihlS UI'IVIfilvt'P(/Iu'ffuM.dNi!irl��i�r,nlracta/�,r sr�.�l� lc'orn�.,�7e .•� . . .,' - -. .. '--� �- ---.." � ... ...._�.�..... _. ._ _. ���� ,tti u d,a.� �n1r t�h',1 iir�.��,l pnr uarct �u ,h�. � - - .oni>d�iu ,l,,un'sc/.�u/. . . . _.. . Fmk�n� . .. _._.. _.. _._ _.. _.._ _ ' . ' I t_�. I am erempt under$ro .B.RP.C.fo.�his _... _._._....._-_ __. ... _ . .. . . . �'� reason . � .. . . .,. . --. ._._.__. . . ._.. __. __._ __.. .._.��___' '_'_ __ '_._....._. .. . . ' . D�te ___. p�N � ...� --'._.. __. _.,.. .,_.... _._�.. ._ .. .., �. � .: Approvak �ote . Inspect r's.5ignafure .,� ,/'� .�r �3 �' TA.N - .. . . .. -- _ .___.,_'_. -. . / U4'(f�' �� -�� � . ���� INSPECTOR'S NOTES - - � ' � . lorn!�on- : __ ._.__....._. ... ._...._.. . . (Se•boc4 E Ynrds) �V/� � -- ._..__- . . , . , . . ,. _.._....._. -_ _. ___.' , � ... , . . , 7 ., . . . �, � . . Foundai'ons � . �� . . . . ��ah �,y ,.�.� , F.�m� ��� �� , =. � � Ener�y In.ulonon �.�IJ��O� �� � -_ .._.._ . .-__� __' ___ __ _.. _ � � � ,. , ,. � .� . . . �i lnih:Drywatl-- �.— . __. _.____ ._ , ._._... , � .. ������, u }y �7� -- . ✓r•>'___ ; � � i�r-e.ie,�a, �z�� 17j �.� ,. . . — , r-� ..�,_ -- . _ � _ _ _ � - .. -,- Hoose Nomn�,_ -.._.___. . ----- .- . � �� ...�.. , _.._______ .._. _.._. . . " ' '__. _. ._ '_ .____ _ '_ _. . � . Concr.r&Pos�ed I � . ,., r.� r�.. ._ .� .. . ..,. ,. ,.- � Fmni. : . _. __._- ...� .. _. . ..,.. __;__'___. • . . . �, E�,i�,en F.oni , . . . ,. . . .. � . . , . , ,,. .. . . . . . . . . � � .. .. � . -. . .. _ . •, , :u � .��. , - ,. , , . \� \�� ;t ` � �y _ ��� •�•. _. __._.