Loading...
HomeMy WebLinkAbout1235A _.__.__._.._---___..__._._......._.._:__ -.�. _ . WORKERS'COMPENSATION�ECLARATION . � <' .' ,. . ..� .: � " -"'-^-- "� .. .. -_" .. � `...'--�- '-' . ` .. . . .., � . __._ . .... . . ' . . �` . , ._..._ � I hereby offrm�hat I have a certifit�le of�o�=e�„a self APPLICATION-�FOR��.BUIL�DING PER�MIT �� insvre,o a ce tificate of Workers'Compensarion Insuronce, o/a cerhf�ed mpy thereof(Sec.3800,lab.`C.)� "" . ' . . . . . . . .-. _ .. . r. .. . . . . . . ._.... . . I. RCS137886 Roya1 Insurance JOB # 213D.14 COUN7Y OF LOS ANGELES BUIIDING AND SAFETY PalicyNo. Company . -. .._;._ . _ '� ^ � Certified mpy is hereby furnished. FOR APPLICANT TQ FILL IN BUit�iNG Sr ��e Cc�� h• � ADORE55 I . �Xj{ � hecounty uilding'i et• -"��- BUIIDING . Doie_�CHISIHr7Pe^'Applitonh' ��� l '�`DDRE55 557 Bre ante Drive � , , ' �_.. Cal-Pac Koofinu. Inc crtv Diamorid Bar -' � '-Z�P'-CA 91765 �ocnuTr t�(.� e�.— I'S o^� � CERTIFICATE OF EXEMPTION FROM WORKERS' � � - - ��-'- - - �'NO.pF g�pGS.�� -- �- � . NEARES7._- . ._ . ..__ .___._, � ' � � COMPENSATION INSURANCE � � � SiZE OF l07 NOW ON LOi CROS$5T,. ��lD '� q ( ( ) 1 he parmit is for one - ..' TRAC�. -.. . ... BLOCK�' - ""' 'lOTNO. - �ESSOR. ,. . .. _. ._, ., .,. -• This setfion need not 6e com leled if 1 hundred dollars §100 or.�ess. , . hUF BOOK �' I PAGE 7ARQl - owr�ERAtr & P1rs C Vannatter TE� •- -. USEZONE �P I certify�haf in Ihe performance�of�he work for which ihis �N�� � � ��,/ Np, ( �"j ' 3 ��� " � -� '} I permit is issued,I sholl hot employ any person in any manner • � � SPEOaL�- �� - �- - --� - 0. so as to become�su6jetl ro the Workers'Compenso�ion Lows. - Ao�Re55 �$$7 BI'C' ante�Drive �- --- - ��la'lrv�'D CONDinONS Q Date � ' " ' ,qpPlitonl� � '. - .�� . .- -. CrtY Diamond_Bar ...--___._ziP Ca ��765 _. . . . - - - � --. - . .. .:.�.. v _ � NOTICE TO APPLICANL•�If, afler making this'Certificote of ARCMITEC70R TEL. _pISTRiCT _ GROVP. NPE FIRE . PROCESSEDBY. ��� Exemption, you-ihould 6ecome subject�lo�the Workeri ---- ENGWEER NO. CON ZONE I Compenwlion provlsions of ihe Lobor'�Code,you must(orth• qDDRE55 (1�_ . {'�',3 _ � '(� �t.� pWV„ with comply wilh�such provisions or ihis�,permir shall be " "� " "� "' -�- � � deemed revoked.. , . � . • � �pNTRACrORCB�.-P8C ROOf1Rg No592-7515 STATISTICAL CLLSSIFICATION APT. CONDO,�� Z LICENSE�CONTRAC70R5 DECLARATION� -- - .. ..._ .i�p -. Cw35 NO. DWEiL�UriiiS � I hereby af{irm Ihol I om litensed under provisions oi Chapter 9 ADDRESS �66-T? W ArrOW Hwy � No 379503 (commencing wi�h Section 7000)of Drvision 3'of the Bosiness ond . . ---_ �-- .uC. � �R�P �- VALIDA � t. ' _ Professions Code,and my fcense is in full force and�eHecr. �yFTS3R D11IlH5 81773 an55 B - ---- -� �- -� � TION �� ' „� . . � . . . � . BK. M,. �ice�se r�umber 379503 ' B - s�ze 2100"'s"roa�s Ciao' �A°,°es one �oNeK ' ¢.Class . _ . .. .- . . . � ' . . . . VALUATION. _. � � , . . comroc�or Cal-Pac•Roofing ptl1e 8/5/87 ---- oescair�ioNOFwoaKRe-roof with Decra NEW '❑ 54,725.OQ ' Tile._21.Squares. ICBO # 3409, ADD ❑ , 1 2"a5A I am exempt under Sec. -� � � . ��- - �❑ - -�. ALTER i Colour - to be advised. . . . . . 8.8P.C.for Ihis reason REPAIR �X ' S .. ..'. .... .. .. .'-� -# " -�''- � �� - � � USE OF DO�e: ex�sriNc ei�. Single family dwellin oenna ❑ f • •5 a 5 0 ' _ __ -" � Signature �. . . -.. " ... -" AP7uc/N7 • tel • . OWNER-BUILDER DECL4RATION pRlNr Cal-Pac Roofing Inc No 592-7515 FINAI n_ • -'j 5',5 O� . ._'_. ._ _ . . . _ .. . . ___ .. . ,. . ._ .. _.. ..DATE./�'.'r '. . .._.._.. _ __ ._ . . ���1 hereby affirm�hot 1 om ezempt from the Conrractor'a Licensa ppOREu 466-P1 iJest Arrow }{Wy� San Dimas . , .;, . ;. � 0&�3�1 -.8 7 ; ' Law for fhe following reason`(Section 7031.5,Business and FINAI���` . �. ..professions Code):. ...... ... �.. _. ...._. .._.._ ___ aE NT -`By-- � -� - . . - . � BUILDING ' � I, as owner of the_property, or my employees wiih qooRcss - . . _. _... _. �, _ -- w6ges os their sole campensallon,will do the work and �. � � rhe structure is nor intended or offered for sale(Section IOCAtITY � , . ,. 7044,Bustness ond Professions Code)._.. . - -�� MOVING - � .....- .... --- - --.. - -� tEL- -. .. . . -. .- _-..- . . - -�--- � - � .� I,as owner of Ihe prop¢rfy,Om exclusively[onfracting CONTRACTOR NO. .- .._ ... _' "_ "..._ ..... ._ __' ... . ._...._.__ ._ . . "_"_ '__ wit icensed confroctors to�consfruct Ihe pro(ect(Sec- �- qDDRE55 �ion 7044,Business and Professians Code). ,. . - CONSTRUCTION LFNDING AGENCY �' ----- -REOWRED. -yqRD'. Hwr' i0iat5eiencK __. _ _ . . ._ . . _ . .. __. . SET BACK CROP.LINE WIDTH I heraby offirm that ihare is a constructian lending agancy for FRON7 .�� ' � � --the performonce of the work for which this permir�is iswed - RL---�-- -- - -�� -- - �-� - �- - � -------- �� -- . __ . - .._.... .. ___ . � (Sec.3097,Civ.C.J. Si�E . ., � .. , ... .. ' '_ . . _. . _..._. . ... P.L. ;...:�.. � Lender's Name � ' ." . . - ....� . - .-� - P.G fee E � -� Pe.mn fea �+S.OD-.. .._ LDMA Raf.k ' ., ,' . . _.. . . . '_._..'_. _ .._ lender's Address . , , � . 1 certif thoe I have read this o lication and siate that fhe ... _ . .. _. _. LO SO _ ►_ . . � � '��-' � � Y PP .. . . -Issuonce Fee • . .._. tDMA G/C.g__ -_'_.-_ . _ :. _. ...� - above information fs mrrecf.I agree to rompiy with oll CouMy i��es�;gauon Fee � ordinances and$lafe lawa rela' g to.building tonatruttion, _ ._. ..___ -- Toial Fee--�-SS.SO� ��- -- �IDMA Perm.-N�--- �-- � � ' . _ _ ..... . . .. .__ ond here6y oothorize represe ot ves of ihis County to enter � - - � upan iha above/-��nenlioned pr pe y for inspection urp ses. 'V\_ . . .:_ f, ,�. �� _. . . .. ..... __... . _ .__ ... . ___. ._ . .. __ _.' .___... _ _. . U SEE REVFRSE FOR E%PIANAiORY UNGUAGE .. Slgnalure of Applimm or Agen� . . . . i�. .' - '.. .. . ...-.. . . _.... ._. . _ . .. __ ._.. _ .. _ _'...Q� PLANS TO APPLtCANT INSPECTpR'S NOTES To: RNurn�d � . • � . ." .' t cenie Law ror u,., ._ � � � ApPIOVBd � U45111CSSp0(IP�nfessiansCade:Anydey.,rmuoi No. Dafe � No. �'-���Dat���.'-. �;: :' -� �. ....-% .��.. '�.�'�=' . . i,..�... , .;- . .requires a f�ermit fn rnnstruct,alter,imfrovc,deniolisl, _. „ , , .':._orrepairamyatructerr,Priortoitsi�seance,alsnrequirce ,} ' , . - . .. � tGe upplicant Jor.tucG permit m fAe o srgned smtement , 1Gat!e ii G«.,.�d p„rsvunt to tbe/�ronr.rrodt of tGe Cnn- ,.�i .� •'� -� �� � � [ractnriLicenseLaw(GapeerYl! . . , ��,n•.�••<:,.a�<�ieb'Ser ' - - — -- _.. .._, r.,,n 7aoo ��1._. ___....__��. �.___.. �__ ��. ' _ . _. ._�_i..._ �' .. _ _ _ �'__..._.__._ . . _ _ ., . . I ortle /JUrviai n 3 Jt7e Uusiness snd PraJc Code)nr 1Gat 1 a ii exe»ipt tbcreJram and t5e ba.i..f ; ....- . � - '-�'_ _�Required �-" � �' ._.____.._.. _.�_ .. '�_._... . _.. _._ _ . arrvaOAlican Jnra.Ar„mYitsubaects hcaptlia 103aa�i! Da1a R�cdvrd, Pe 7 p i ApProvah -:.Yas No or Approvod , ., „� ... ,-.hranity nJ not more tban J ve GanJred dnitnrs(SS001.1:. � ._ _._ "._. '____ .. �- - � - - ���-�- - �-� ❑ 1,as owner of fhe properly;or my employees with Water Cenifitme :�� �, �� . :. ,, . i , .. � � � � -� ,wages os fheir eole compenspfion,will do Ihe work,and ____.. ..__ . _ _. I . �-------- - - -- - --- - �� �-�� _ - - � , �� � � �he stru<fure is not iMended'or ofiered(or sale{Sec.�7044) • ' � � � � . Busines.r�andProJessionsCode:Tlc�Coneraomri[.i�enre :. HeohhDeportmenl._._ . _._ _ � . �� .- _ -- . . .. . . � __-� _.._. ____.._. _ .... ._ ._. � � . l.ou�dnes xoi opply fo an amner of property u�Gn builds , fireDeponment _ ,_- .._._ -.._ . .. . ._ __... ' ,.. . . �. �' , �frooestGercon.anSa�Gndnessar!uork/rmsclJnr . �. � � ., .t! ugl.l it-o n e�+playees,�prnoided tbat sn<! im- Groding � � ' , .�proocmexts are.nol intended nr.nffered fn�snle.�1/, � - . • • ,.� . . ., � ^�•Gnwci•eq the 6uilJing nr imprm�ement is sofd udtl in vnr � _ _._. __._.. .._ . . .__ _ '... _ . . . .._ '. �" 1 Geo�ogicol. � � . . . . . . : . . -. . ... �ear f completion, rle�ou•acnb�ilJer�mil!bar�:tlr � burden f pro�an,q 1l�nt 5e did noe buiiJ or impmuc frir r __ .. . :.1.:'.._ . . _'_. ' _.__ .. Pedestrian Proleclion � t!e f�urpose f suf¢J.�� _ ' � . :'�..' ,: �.. : , ��.� : ..:� .:. (Fence)(CanoPY} . .. . ,.-. .� . .. .---- -' . . ..�.... . �-..'-�_... -.-..... . '� `�❑ I:osownerof the properfy,om e d�sivelyFontioc- . . �-.ting wtth licensed conlrac�o.s fo constru<t 1he project(Sec. Speciai Inspection--" : . . .. . _... . ...--�--�-: ' . ��- ��:� .�� -.. . o ess . � on ar ___ 70a4)Qusiness anJ Pr J 6ns CoJe•TGe C tr tar's (Conc.)(MasonrY)(Weldin9) . � . . . _ . . . . ' ' I.irenae I.au!does nat aprly�tn an ou•nrrnf pmperry u�Gn - - . —� builJs nr impm�rs 71 crenn,nnd u�l>n oontrarn for sacG Lm Drainoge � '. � -� -- - �� � proJc�ft with p mntmrtor(s)Jicensed pursuant to ebe . _._. . . . _._ _..�__-. . - . . , � . �--"Canerador's f.icense fauJ. -- .__ .__., . Porking . � - . .... �. . � _.. . � ___�. _. _ ._ .__. .. __ _ ..-.�'„� . �:c:� �� , . . � 1 om eaempt under Sec ,6.8P.C.for�hi� � _ _.__. . .. . . _ ..__ .. • ,..�� .. .. ., , . . , , , reoson , .. . ... .. .. . . '_'___". .,_ .._._.___ ..__-_.,. __...._ _.. . , , , Dale Owner Approvais Dofe Inspbctor's-Signaluro - ' .. . � � , . ' , . �� ' INSPECTOR'S NOTES � � � toca�ion— . . . . .. � _. .. , . . . _ . . (Se�back 8 Yords) ��� � � . . . . : Foundotions � � . _ . -. .. .. ,•- .. ,.., ... �� ...; . . . . Slab Frame � _ . . . � � ,. � , . . Energy Insulbtcon . :..�..�. _. ._� __ ._ . �_ ... . ...— �I_.._' . .. .. . . lafh/Drywall— _. __'_ _ .. __.__'___.. '_ _.._.__ .....___... .. �� . �� 1 . . Imerior ._""__ "_'__ .' .._.. , �- . . � lmh—Exterior � .. . � ' �" � '.�.. � . . . . .� . . _. ._ . ....:.. HouseNumber— .__..__. .___. .. __. __ .-. -___.. _ .... , - ... . .. Correcl&Posted � . . -- � . - --. -. - ._. , � ,�! Pinal— ..__.__. .___. .____ ._._ . � .. .._ . ......_ ...... _ ..__ __. _ _._ _. . , Enter on Fronf . � ... . . . � , . . .. ��. . . . ..