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HomeMy WebLinkAbout1605A 1606A (9) � WORKERS'COMPENSATION DECLARATION � � I hereby affirm thot I hove o certificofe of consent to self qp�pL�CATION FOR BUIL.DiNG �PERMIT insure,or a certifitate of Workers'Compenwtion Insurance, or o tertified mp thereof(Sec 3600,Lab.C.J � � � � � 7�3W�005-2'�9-001�6 30/B COVNTY OF LOS ANGELES BUILDING.AND SAPETY Po icy o. ompany Nati t'�rttai rlt�. � Certiiied copy is hereby fumished. FOR APPUCANT TO FILL IN Bu��oiN� ADDRESS 24411 Dee s rin s Drive � Certified copy is filed wiih the county building inspec- BUi�DING lion depariment. ADDRESS Date 8-1$—g� ApplicontT� �DIN ��� aTr Diamond Bar zia 91765 �ocnurr Diamond Bar CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. NE4REST COMPENSATION INSURANCE - SiZE OF LOT NOW ON LOT CROSS ST. 'p & ZCZPR S rin S (This secfion need nof be compleied if�he pe�mit is for one 7RACT 42589 BLOCK LO7 NO. �ESSOR - � hundred dollors($100)or less.) MAP BOOK PAGE PARCEL OWNER� .a.NDIN GROUP NQ967-9541 USEZONE 1�✓+ y� I certify that�in the performance of�he work for which rhis �.--( �`10. t E� �� permit is issued,I shail not employ any person in pny mpnner SVECIAL � so as to become subjectlo the Workers'Compensation Laws. P.DDRES�.O.BOX 3329 f3�5� CON�ITIONS � U CITY ' ZIP � ��ale Applicanl OiSTRICT GROUP TYPE FIRE PROCESSED BY ^ � � ARCHITECT O TEL - 1710E TO APPGCANT: If, affer making�this Certificoie of ENGINEER �ave Szany AIA No445-4073 CONST. ZONE � ...emption, you shoold become s�bjetl to �he Workers' Z -p � Compensa�ion provisions of the Labor Code,you mus�forrh- qDpp¢�5 314 N. First Arcadia 91006 1� �'�J' ��F �+-i with comply with such provisians or ihis permit sholl be TEL.- - - �' CONTRACTORTHE ANDIIV GROUP STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. � LICENSED CONTRACTORS DECLARATION N�,� CtaSS w0. U� Dwell.UNiTS fi� I hereby affirm ihat I om litensed under provisions of Chapter 9 ADDRE55 j�$ �OV2 NOrj1��j(7� (commencing with Section 70D0)of Division 3 of ihe Business and ��� SEWER MAP Prcfessions Code,and my license is in full force and effect. CITY C�A55 BK � VALIDATION 510560 B s°eFT1786 S7DRIOES FAMILIES 1 CONEK License Number Lia Class �{� VALUATION� THE ANDIIV GRO�P 8—�.$-87 DESCRIPTIONOFWORKSITI le famil NEW "--' S 8]_,650 Controcror pte ❑ , ADD � i �11:5G ❑I am exempt under Sec. Y'd e 447 SF q�iER � ❑ ; �21 B.BP.C.for this reason REPAIR „ � & � Date: USE OF DEMOL � o r b�}�j� EXISTING BLDG. � Signafure APPLICANT... .. . . .. TEC . . . .. FINAL — n� '--- OWNER-BUILDER DECLARATION PRiNT) NO. DATE Z � ��� � ����"`�`�" I hereby affirm that I am exempr from the Coniractor's License . _��7 Law far the following reason(Section 7031.5, Business and AD�RESS AS d]JOV2 FINAL ,fj� ��f�j � ,. rofessions Code): - � � � By ��/�/g.n-ci � J I, as owner of rhe properiy, or my employees wiih AD�DRESS wages as their sole compensation.will do the woik and � the shucture is not intended or offered for sale(Section LOCALITY 7044,Business ond Professions Code). MOViNG TEL. ;I i:u(��.. � I,ps owner of ihe properly,am exclusively coniracting CONTRACTOR NO. c c with licensed tontractors ro construct the projetf(Sec- qDDRESS t� �� a � �ion 7044,Business and Professions Code). CONSTRUCTION�LEN�ING AGENCV - � RE�UIRED ypRD HWY TCTAL SETBACK F IS. . i ^�.;.�j%Cj�j SET BACK PROP.LINE WIDTH I hereby aHirm thaa Ihere is a construction lending agency for FRONT I f �he performance of�he work for which this permil is issued P.l. ° "��`��,ri�'� (Sec.3097,Civ.C.). SI�E P.�. OQ,1 ? -8% lender's Name C1t1bdTL�t 444 S Flowex, L.A. 90017 `o""°'Re'.n " tender's Address P.C.Fee$ 268.65 Permn r-ee 4'�J1.5� ' � I certify thof I have read this applimtion and stafe that ihe issuan<e Fee Q, IDMA P/C 8 above informotio is rorre<t I ogree to comply with pll Coumy Invevigarion Fee ordinonces a ate laws relating ro building ronstruction, 7otal Fee �DMA perm.k ond hereby u rize esentatives of this Coun�y to enter r upon enli e p rty for inspe�n purposes � � � 7 �„ �_� LDMA $75 $35 ���f� SEE REVERSE FOR EXVLAMATQRY LANGUA6E Si9nature af Applicont or Agenr D�le ,.__.._.___.____._. __ �_. _._.___.,�.._�.._.,.____._._�.�___._..�, ___ ..._..�.,.__,�._.�_�r__ , , ,� ��=.,ex� �a;€s ,���^�; >�,��.�, s� � ��_ < � �. _ .___._ _,.�__._._._ .� w�. , r _ __. .�.�. �... � _ , -�--- 4( w: � i �€a�. d . -� . . . .. . . � � . o..A� �___..... _..... ._—____ ,. _....< <._.._ .__._ .. �_. _ - R � v( /1 Q, ' _"_... � � __�:" —_�- ._._'Ji.. '__�.�' ' .. . . . 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