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HomeMy WebLinkAbout1574A 1575A (9) WORKERS'COMPENSATION DECLARATION - � insurebor�afcertifkatieofWorkers'rCompensaton��=�;a��e` � � - APPLICATION FOR BUILDING PERMiT or a certified copy ihereof(Sec.3600,lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY 73wc005-2��—�(��6 NATIONWIDE 36 B Polity No. m � Certified copy is here6y 4urnished. FOR APPLICANT TO FILL IN qDIDRE55 23610 E. Chandelle Place � Certified copy is filed with Ihe counly 6uilding inspec• euItDING tion deportment. ADDRE55 Z3610 E. Chandelle Place Daie 6-30-87 Applimm THE ANDEN GROUP arr DIAMOND BAR ziv91765 iocnu�v DIAIdOND BAR CERTIFICATE OF EXEMPTION FROM WORKERS' - NO.OF BLDGS. NFaRE57 COMPENSATION INSURANCE Si2E OF l0T NOW ON l07 caoss sTDIAMOND BAR BLVD. + GOLDEN �This section need nol be compleled if Ihe permit is for one rana 43435 BLOCK lOT NO.45 MA�BOOK PAGF PARCEI hundrad dollars(5100)or less.) owNeaTHE ANDEN GRODP No.967-9541 ��}°f E "1A° //'7-3 I�certify that in the performance of Ihe work for which ihis �. NO. permit is issued,I shall not employ ony person in any manner ' SPECIAL Q so as to became subject to 1he Workers'Compensotion laws. ADDRESSP•�. BOX 3329 000� CONDITIONS v aTr COVINA ziv 9ll22 a Oate � APPlicanl ARCHITECT OR TEL. D15121GT GROUP tt7E FIRE PROCESSED BV O rNOTICE TO APPLICANT: If, afler making�ihis Certit�care of EN�iNEEa DAVE SZANY AIA No.445-4073 �a E � Exemprion, yo� sho�ld become subjac� to the Workers' . n (� Compensation provisions of tha Labor Code,you must forih- qDORE5531L1 N I �� (J�3 � ? �z a wilh comply with such provisions or Ihis permit shall be TEL, STATISTICAL QASSIFJ�ATIDN �� APT. CONDO. (A deemed revoked. corvTenttot�'HE ANDEN GROUP No. LICENSED CONTRACTORS DECLARATION IIC. M55 NO. ��� �WELL.UNIiS Z I hereby affirm thol I om licensed under provisio�s oi Chopter 9 ADDRESSAS ABOVE Na.510560 ��R�P (commencing wilh Section 7000)of�ivision 3 of ihe Business and LIC., Professions Cade,and my license is in full force ond effect. CiiY [in55 BK � VALIDATION � �510560 B 5°e�'�1658 S ORIOES 2 FANIOLIES 1 Cp EK l(cense Numbe Lic.Class VALUATION ;� 5'j,(�,Fl DESCRIPTIONOFWORK N � ComractorTHE ANDEN GROUP' Date 6-30-87 Aoo Q S 100�000 �. . . .2� ❑I am exempt under Sec. GEIRAGE 4$6 SF AIiER ❑ , ( •3 1 6 8 4 8,8F,C.�or this reason REFAIR ❑ _ � Date: USE OF OEMOL • ��1 G�4� EXISTING BLDG. � SlgnafurB AFPLICANT TEL. FINAL �/..�y/� O Q.� � `�7 OWNER-BUIIDER DECLARATION vRiM THE ANDEN GROUP NO. pATE �--•, . I hereby affirm that I am exempt from the Camractor's license . Law for fhe following reasan(Section 7031.5,Business and ADDRE55 AS EIBOVE FINAL (/� Professlons Code): ' - - BY ��/'�<'v`��� +-1 BUiIDING � J I, os owner of Ihe property, or my employees wilh ADDRE55 ;"� J 7.5� wages as their sole compensation,will do Ihe work and � Ihe structure is not intended or offered(or sale(Setlion tOG4LI7V �o e . . . 1 704a,Business ond Professions Code). - enovwG � TEL � � I,as owner of the property,om extlusively tonlrpcfing CONTRnCTOR NO. ' ' i��7 O O with licensed conlractors to construct the project(Seo- - tiOn 704d,BVSine55 OntJ PrOfeSii0n5 CodeJ. ADDRES$ . . � Q J O 7.L�O� CONSTRUCTION IENDING AGENCY � - SE�gACK YARD HWY TOiAL�OT���NE Wi�TH . � I hereby affirm that there is a construction lending agency for FRONT . .., , �9', 1 �8 7 Ihe periormance ot the wo�k for which this permii is issued � v.L , � � � (Sec.9097,CW.C.J. SIDE , CITIBANK P.�. 1 Lender's Name ��Ref.* . ��c..; 444 S. FLOWER, LA 90071 v.c.Fses 316.84 ve�mirFe> 496.50 � • g tender's Address 1�.50 g I certify thot I have read Ihis epplicalion and ata�e fhat the �uua�ce Fee iDMn P/C M above informofion rred.I ogree lo comply with ail County investiqanan fee r�07.QO $ ordinances and at laws rela�ing to bullding eonetruction, Towl Fse tDMn v�rm.N � R and hereby e reprosentotivas of this County�o enter � upon e e ' ty for inspection p rpoees. LDMA S75 $35 Z SE!REVlRSE�OR�X�IANATORY IANGUAGF � Sipnmuro of pPlicanl or A9ent pole � FlANS TO APPIICANT INSPECTOR'S NOTES . bA'\l�.lt.11UII.UI�.H UkC1.Akr\I101 . . I he.eLv oth.m th�i I am�•ze,np�frcm r e Coni•oc�or's � To: . � . ' . Re�urned . ' � - , � . � . � Lice�,se La�N fn• •he �ailow.n� r n•,on (Src. 7031�Si HPProved � ,. . . . . lJus :rscrrnJl'rqlrsri.�naCndc:,An�,•cih'pnvunh'u�hicl No. Da�e No. '�"Dofc � . .. . . • . .. rryi.irec�prrn�it 1��on,n�n��t.-ehrr,i�nJ,r,�rr.ilrnn�liJ�, -.---�--'--- -- '--- , . - ,'r.epairunvxrructrne.�/�rinrr,�,rtxr.c.ivai�:r'.JI.<nrrqr�irrr . . � ' ' � � . � . . �. d>e a/rpli:an�/nr cu:h firrni��u/ifr,�r si,P��rd r�J1.•nrrnt _ I- tGa!hr ic li:en��-Jfiurtu.rrtt tu d�e•frnr•ia'i��nc nl!!,e(:or�. . � � . .. ... �!i' trn.�lnrtc l.irrn���l..ur(Cl.apt��r 1/(rnuinirn�in,G u�itl�Srr. � . i . . t.. .. -_._ _ _. _ ._. .. -_ _. . _ �_, , linn 7(/OOJ oJ,Uivicinn 3��1'1hr liueinrsc��xd l4��Jrroinnc .. _ _ ._ . . _ � . �� __. . . . _- __ . ..... . . __ (.•rJrJor th�t!•<•i�i�.rrnrpf d�rrr/rnm«nJlbr hrc�i..�or ll�e �i!le.�rJ exrmp7inn:Arcv riul.�tinn n/.1��rinrr iP3(.5 G}. .. . ' - .'Roq�ired � � �� -. .. . _ . . , . . m�r�ppli:dnflnrapenttitsuhje:ttlLeaffliaanlrna:ird! '�Data Re<olvod ApPravols . .. Yos No or Approved. . , . fenu!!V�+/nril��rnr�•ll�n/ir•c l�undr.•J J�illn.,/55�iuJJ: ___ - A. -. . . . . .. ... .- j�., I,ns owner o(Ihr propr.•Iy.�a�my emplcy.ces w,•h W'o��:r Cr•r•�h:aie -- . ' . ' .__ _ .. . ._ . woges as,their sole cort�pensqnon.w�ll do Ihr..ro�b.�nd . ._ . . , , the stroUwe is no�inie�drd or okored fo��sa!r(Se: 70�E4� Ft„alih DePnnmen�. _. . ..: .' � . Uu-ciuess unJl'ruJrssi�ms(�udr:,7�Le C.�nh�ar7nr51.r.ensr ; _-_- _'_.' _ . . . _ . _ _ .. . __._. . ' . ' 1.�ar�/nr.a rro�up/,lv!n rn.�u•nrr�r/p�oferh�v�h��Fui7J.. � . . nr irn�rarr.�Ihorrnn,and erhr�dnrs xur!�rurJ:him.�r//nr F��o D��po.imFnt. . . _ . . .. _ _ . . 7. � � J - - . _ .. . lLrnu�lr 1�rc nirn ivufr7�{peac. pmrrdr�l,t!✓t re,l� im-,--' ���ocLny� „ - -nrr�remeafs Rrr nni rnfrndrd ur ��//rr�-d!nr trd�.,!!, � " . � �Lnuv�+�er,tbeh�uiJlnXr�ri�.epror�rmrnris.�olJiriel,u���nf� � t'rur h/tnnr lr�i�.n, tbr nu�urr.l uild�r «��rr n���•� tb�� Geolnq�cnl. - - � - � � .. . . . . . . . . ' ._ . . , br<rJrn�,rrrr�•�,�x l�,�,r i�r Jid rcnt f,uNJ nr rnrprurr/.i• i '. !b�purpu�i�o/�alr/. Pedenrion Pro�eUion � ' � . � .. . � . , ' � . ., (Fnncr.l�Canopv) � . - . ---- -- - -.- - . . �.... � - . � .: ,. �f �I.as own�r of thr p.operty.um c�dvs�vcly ronn:ic- ' . ling with licc��sed co��rnUor5la cunsrru�t Ihc prol^c�(Sec. _..'- - ._. . .___ . _ 70aa)fhaini�.0��nd!'rul�uri��ns C��dr� '!'Lc Cor:rre�t��r's Specinl Inspaction . � ' ' (Conc.)(Masonryl(Wclding) � , _ . _ .. . . .._ . . . .___ _ _ l.i�rncr f..itr dnes nn�dpp(y lo Jn nu•nrr r f proprrtl'u•ho �huilJz�or iuiprorrs�hi�rrrin,uni!u�d�n t mero.ls/i�r su.L to��rmnn.�c � • . . - . . � � _ .. . .. prujn�ts u�itl�� a n+lraatnr(.iJ lircn�rd fnr.�udnt tn !hr . . . - f.��ntrrt.l��r't l.ice.isr 1.�+u•J. . . .� -�- � . - Fark�ng . , . . _ _. _ __. . .. . _ ." .. . _ . -. `u � , �_.� I am r.Rempt undcr Scc. ,B.SP.C.fo�i s , ___ rmson' __ _ _.. . . . _ . .. � . . - . � .. _'_._ _. '_.. ..._' . , Da�e Ownrr � _ Approvnls Dato Inspacfor's Signelure , � , � � � , . � _'—_— _� � � �� �INSPECTOR'S NOTES Lnmhon-� ' --- --_ ISe�bock&Yards) ._. . . . . - .. �-�•_ faund�Gons ,. � " � � , Slob __ - __. ... __�_ -__. _ _ _ .� _ . , � . .. . . � . F.omP ' I I L� �� � IQ ,� /�, n� e Energy Insuianon _ � . - ._�- - j-'. . � , . . _ . . . ,• .� . - . laih:Drywoll.. Z��� _. . , , , .... , . ,. . ���A„o, ��2�_c� . - - __. . .' ._'_' .'__._. ._'.-... '._..'_. - «�h_Er�P�o, �.Z�_ � � _ _- --_ : - , - ,,. Ho�se N�mh... . _____ ... . ..-. . .. . . � , ..__" -- . ..�.. .. . �.. _ . ., Cor.ecr 8 Pos�ed � . ., -- ._. _. . .._____ ._. .-'. .� � . . .... � . ..�. . �. • . Finai -___ . . . . . _. _ . . . Ent�r en Fronr ' ''��'� �. �� . ,� . . � . . . - - `- .;,-�\.� � . . . . . � . . ' . ��:`\��°- - -�.�,�:,� '1•� .._,