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HomeMy WebLinkAbout1558A 1559A (9) WORKERS'COMPENSA710N DECIARATION � � I'hereby affirm that I hove a certificote of�a�,e��,0 5e�f - APPLICATION FOR BUILDI IVG PERMIT insure,or o certifica�e of Workers'Compensafion Insurence, , or o ceriified copy thereoi�Sec.3800,Lab.C.) � Polic No.�3wc005-2��m�6 NATIONWIDE 61 B 2 CaT �OUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Y Certified copy�s ha�eby tu.n�shed. fOR APPIICANT TO FILL IN AppRE55 23604 E. Chandelle Place � Certitied copy is filed wilh Ihe tovnty build�ng inspec- - BUILDING tion depariment. ADDRESS 23604 E. Chandelle Place Daro6-30-87 Appl�mmTHE ANDEN GROUP crtv DIAISOND BAR zidJ1765 �ocAurv DIAMOND BAR CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. NEnREST COMPENSATION INSURANCE SIZE OF l0T NOW ON l0T caoss s�IAMOND BAR BLVD. + GOLDEN SPRIN S (This section need not be completed if the parmit Is for one raacr 43435 BLOCK LOi N0.44 Mqp BOOK FAGE PARCEI h�ndred dallars(5100)or less.� owNe�IIE ANDEN GROUP No967-9541 us�oNg No? �3 S I cerfify 1ho1 in the performonce o�the work for which Ihis � permit is iss�ed,I sholl no�employ any person in any manner SPECIAI �, so as to become subjec7 to the Workers'Compensation laws. AD�RESSP.O. BOX�33Z9 d�1�c7 CONDITIONS � aTrCOVINA ziv 91722 � Date Applicant qRCHITEQOR iEL. �NOTICE TO APPLICANT: If, oile�mpking Ihis Ceriifitate af ENGINEER DAVE SZANY AIA No.445-4073 DISTRICT GROUP �NS FZIpRE�� 7ROCESSE�BY Q Eaemption, you shoold betome sub�ect to�the Workeri �� �2 �� �„/ W Compens�lion provisions of the Lobor Code,you must(orih- qDDRE55 ' ✓ �V wilh tomply with such provisions or this permit shall be 1EL. STATISTIG4l CL4551FICATION APi. ONDO. Vaj deemed re�oked. Cot�ruqcro�HE ANDEN GROUP No. �` Z UCENSED CONTRACTORS DECLARATION . . ���, QASS NO. "v DWELL.UNITS� I hereby affirm that I om licensed under provisions of Chapter4 ADDRESSf1$ �.$��1� NO.51�560 SEWER MAP (commencing with Sec�ion 7000)of Division 3 of the Business and liC. Professions Code,and my license is in full force and eHett CiTv �LnSS gK � VALIDATION 10560 B s°e�2634 s"roR°s 2 aMi°is 1 o E� License Num6e� Lia Class VALUATION ContmctoirHE ANDEN GROUP G�3O�H7 OESCRIPTIONOF WORK NEw Dale App S 1S7�OOO ❑I am eaempt under Sec. GARAGE 445 SF A�TER , �1 5 5.8 N B.BP.C.for Ihis reoson REPAIR s � �m o • •2� �a�e: u5E of oEMOI Ex15TING BL�G. I •& 1 8.5 9 Signatule APPLICANT TEL. FINAL ,+a� OWNER-BUILDER pECLARATION PR��`�T THE ANDEN GROUP N�� ppTE J ?y�` • 1 hereby aifirm�ha�I am eaempi from the CoNractor's License � �°�+� u J�� Low for the following reasan(Section 7031.5,Business and /�DRESS AS ABOVE 81NAL �;'*� �0 .� 1 _�7 Professlons Code�: k N 6/�� �^� I,as owner of the property, or my employaes wilh A�DR 55 woges as iheir sale compensation,will do fhe work ond �p�q�I7V ' 1he slrucfure Is nat Intended or oifered for sale($ection �� 5 J�.(�A - 7044,Business and Professions Code). MOvwG . - , iEl. � � I,as owner of the property,am axclusively contracfing CONTRACfOR No. 'r� � �� � , with liceneed contractors ro construct the project(Sea �- qooaess � tion 7044,Business and Professions Code). � ' I •6 7 S�Q REqUIREO TOTAL SETBA K ' .� � CONSTRUCTION IENDING AGENCY SET BACK YARD HWY PROv.LME WiOiH - ' i hereby affirm ihat there is o cons�rotlion landing ogency for FRON7 . • °U 7���� Ihe performance o�the wo�k for whtch this permit is issued - v.i. � ' � - - . • � (Sec.3097,Civ.C.). , SIDE O 9.� � "�i 7 CITIBANK P'�' Lender i Name �. ,-�, v.e.cee s 418.59 ve.mn Fee 664.50 wnv.eer.r :` . g lender'sAddress444 S. �FLOWER,�LA 90071 - 10.�J� ' g 1 certify that I have read this applimtion and state Ihm Ihe i,s�a�ca Fee �DMA P/C N obave information' carrect.I agrea to comply with oli Counfy inve�iiqation Fae $ ordinences an f e lows relofing to buildinp construction, Toml iee 675.�� I�MA Perm.M & ond hereby o� r(ze representarivee of thfs Counry to emer � upon the roperty for inapeUion purpoaes. $']S $35 - iLCREVERSF FOR Eff�UNATORY LANGUAGE ~ Siqnature o� �i<anr or Age�� � � � ' PLANS TO APPLICANT INSPECTOR'S NOTES ..:Ol1'M!It-13LI11.1)I•,R U[CI.AfiA 11UV , I hn•rF,y c�ffnm itiot I am eMemp�1ror�il�e Coni•uc�or's � To: . ' ,.. ,. � aerurnca'. � � . � � „ .. Ccrnso..ta�.+ io� ,hc.followin� r ., n (Sr.'�7091'S; Appravod I)uda�:cc unJ!'rv�rs�ium Cr�dr:An��citt'os:nunh•u�hid� No. Dato No. -... Dafe,, . ... . . . . � •. �... rcyuirc�a p irrnrl 1n rnr>>VuoL aRrr,impr��r��.Jrmnlivlr. . - - - - — . .--- - .. � �r r.�p.ur un��sfrurhirr:priur h�itc ic�i��uu�.uLu rryru . . ��;� ' � . . � Nn�u/�plr:¢ttf jr.r xr<d,J�rrnrit 1n�I�C R.fl(�)ifll S(JIft�1PAl ;. ;. . i . . . , i... � .. � � :. : _ . •,- .�_ ___.-- ' . _' -._ .' ._ - _-- - .thaihciali:rns<�dparsuanit�itbrprnr•'n�nn.an/(h��(:.m. ... . ` . � � �rn:�nr:�l.irers.�•!,�«�(CJ��rpr�•.')l�-�� m��ucin.4�rithJco . i . , ; . ,;, ..,,; � . ._ .. .,. m _ ."'. . " _ .' ' ._. ' ... . . .. . _ . _ _ .'.. ._. .... . _. __ , (i<,n i0(1lqn/fJiri�i��n 3 oj tPn liu�ina��anJl'r�./es�i�mc ; , ..., �. ., � . ' �.(l. C.+drl ur d�d� �pt tLcrr/rom unJibr hn�is/�,r fhr '' _ .__..... .. _ ... ... . . ' _ . . ._ :' . ��f tt�.YI'�l . . .___._. ._ _- . uU<'.4eJ excmp�run..1nv rinlatrnrr/.t��'lrnn7U31.5 hr ,. .-. _ �„ . . Rnqui�ad = DaleRoceivod _._. _ . . .. :,,_ _ __.__. . . . . . .. _ . _' ✓rscdrpli.-anl/�..«rrrnr.t.��r�hjr:rslbe.ipf/ic�mtfoa:iril Approvals , or Approved . Prnalts n/��nt mnrr tbm�/irc bu.dn-d J��ita:,(c9n01.). ,,. - ' � ....Yes No._... . . � . . ' , .. . __.." '_: � .- . __ _ . - .. . .. � � I,as owner of�he propnny�'o�my rmpioyc�.s w,�ti N:n�.c�Cr��hca'e � � � . - - � ' --- - _ wagns as Ihe�r scle compensairon.wJl�1e ihe.�orL.and ' - - ����� � � � . ., the srrcctu�e is ncr Iniended or oHe�cd fo�sale(See 704�1 ' " �� .' � •. ' ' (insine�sundPrn/�•ssrausCudr:.7'brCnntr,ectur:.l.i:rnsr Henl�h DePanmen�.. ._. - -.- _ .. . __. . _. .__ _ . . ._ . _.._ . _ _.. ...._ . . � . . � , Lm�Jnrs nnt uppl�•7n au mrner nJ prnpert�•�rbn hurld.. ' � f�.r Depa��n�nt'_'._.- _... __ ' ___. _. .. � � ' _ ur irrry�rurrs tbrrrnrs.und u•Ln doea su:l u�url,l,inise!/.rr � ' . � . � . ' l6rr�u,�b:his n��•n.emfluyr�•r. J,�nriAcd tlat�.aecb iin-^. � G.nd�ng �� � " � � � /�rvn•rnrcntr•¢rr nrit inlrnded!ur.��//����J fur.ealr. 1J '1, a' '�� . • . � . boeeei�er,elrr brrilJin,¢nr rrn/�rnre�nrn!i.c m!J irrObin nnr � ` : � • .� ;. .; . ,� , _ .__ ._. : . . . __ '- -- --� - - --- - .. � miorerhruldrr �rilf hnrr thr Gecior�cnl�. - . . . . �.- � . . }�eur n/enm/�7etrnn, fL,e , �� '.. "• _.__ , -_.�':-.: . .�: '� _�._:.� . .:. hurJrrs n/frnr�iri,�tbnf!�r Aid nn7 huilJ�nr inaprurc/nr PedestrlanProrection.''� - ,� � . . - .� . . . . . , tb p�r/�nsro/salrl. �- �� �,- ;. (fnnce�(CanoPY) . . , . _I:-� . . __ ._. . . . . . . .. �.. P. P.rs', ' Y< �� ��. 7,as owncr of rhr o c t 'nm e�clvs��cl onva . iing wid�Lcensed contrnao�s m coouruci ihe pro�ec�ISec . . . � _.__ '._ . . _ __.__. . . .__ __... . Speunl Inspeciion , . - - . . .. � .. . .. 7044)Uasirsec�urcd Prn/rcdons Codr•7'be Cr.ntr�cen>'s �Concl(hlasonryllV:eld�nq) � . - . .. .. . -. . _. __ . . _ - . . Licrnarf..�e��dr�C3110fdf,pll'�nannu�urr���p�nperhu•L.� �huild.a or irrri rne•rc iLrm�,�..,��J u�l,n b,nlructs frn�serfi lot Dr�inoge . . ., . . .. .... _ - . . ... , /+rnjrctc,udll� a malr�rtnr(s/liaburJ rr�rs��ant 10 1hr � . .. . . (�rinfrnilnr'x!.l[PnsP l,nv�J.� fnrki�y �� ,f _..__I .. . __...� . _ .. . ;.i . � - . � �am c*em �undur Se�. .6 EP.C.�o�fh�s .__.__._.__.._.._. - -'. __. .. . . ' ' ICU50� .. . � . . .r . _ _ .__. . -.... . ..-. . _ . . Daie Own � � ' � �, . . . _. . ._._ .. . _ __ _ . . . . �- � . ..._._ ' _ _ __. . - � . . . _ i .. Approvals Dafo In�pector"s Signoturo . ' � � . , � � �� � . � INSPECTOR'S NOTES � �- tocuhon'� ' . ' -_ - .'- . . - ISeiback 8 Yardsl ' .- .____'._.._ � . . � .. �. . �. .--• FaundaGons � � -... , . . . . .. . Sia6 . _. ._ _r� 3d � . . �._�- .. � . . . i . framee � � IQ .. . . .� . . . .. . �. .. _�_I _ � . . .� . . fn��gy Insulai�on ( . .... .._ '._. _..' .._ _ _...' '__- _ . . , 11 4� : ln+h;Drywall. � . ._ .._____.._____. ._'__ _ .. . _ . � Z �Q� - - --- -- , � - IlIIPI�O! � laih._Ex�eno, y : � . .� .. '�. - . .. . . . � � ._. :__ � ,� _z -6g; -- - - _._ _ _ -- -- ._ _ ,. Hm�seNumhr.._ . . — _.-_ - __.. ."__ . . . :� . ._ . .. . •� .._... . , ., � , __ . _ -. ___ � ,. - .,- Cor�ect 8 Fosred � ' �•�!� � _-�� � � � . Fm�l . . _. _ . . ......' ' .__. _.._. . . _ . . � . .. Enrer on Fron1 , . �'-� ��' \. . - , . ,� .� . , . . � .. . . .. . .� ,, . , .,. � � . � .: _- ``.` �.\,--,\*_��— . , . . . - _ _. �.Z . _