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.,� , ., . ,. „ .,, - ._ _., __.. ._-_....��w ....__.._ _ .. . .... ._ .� ._. ----�---�_ _ ._ __ WORKERS'�COMPENSATION DECIARATION �'_ � � •''- � . � :- , �,��. � •• insorebor�afcertiFca�reofWokers'rCompenotonlnsoronce' -�-������- - ���APPLICATION F4R :BUILDING PERMIT.-��--�-��:� �or a cerrified copy thereot Sec.3800 Lob.C.)..,. "... -----.. ..-.- ... --�- � - -- - - - �- � � ' .. . + ' • --•-73WC005-2 9-0016'' Nationwide 1/B COUNTY OF LOS ANGELES ; BUILDING AND SAFETY � , � ,.c i _ . . - -- -- . Po11tyNo. . . - .�.Company ... .. -- .... . .. - - a•� CerHfied copy is hereby furnished. . FOR APPLICANT TO FILL IN ADDRE55 520 Jon Cot1Lt ��- C�erlified�copy�istiled,with�fhe:countybvilding�inspec- ---�- � gU0.oWG . , . �Hon departmenl.'�-� ADDRE55 20 Son Cou t � , ... .-'... . , , � PP�.�. �. ., . - ._- - -.._ . . . . Dale��-�����8187 A� licam THE�,ANDSN„GROUP cirv Diamond Sar ZiP 91765 ��i�TY Diamond Bar "` �`CERTIFICATE OF EXEMPTION FROM WORKERS'� �' �--� -� --- � �-�� -- � �No.oF etocs. - - ; n�qeEST... :. _ � .. .' � " "�' 'COMPENSATION-INSURANCE"�"�.. -'� SIZE OF LOT nrow oN�or � c�oss sr. Diamond'"Bar B1vd:/GoTden-5prings (This setFlon need nor be'completed�if��he permit ii for'one �-���-� -- -� � �-�� --- ����-�� �- � �-� �� ��-��-� �-�� �� ��� �P B� � . PAGE' PARCEi I hundred dollors(5100)or less.) ., . ,__ , . , Tanct aiocK toT No. � � .. � .. � ,. . . Y P ' -- No 967-9541 u ZONF r.uP owrha --THE-ANDEN-GROUP � �� } so as'to 6emme,sub'ectFto he WorkerseComrk For which this ��+ �� � permit is issued,I shall no�employ ony person�in ony monner ' � SPEqA���--� �� -----� � � � � �-� -�� -� . - ADORESS.....P.O. Box 3329 --.. . _... . . .._. � Oet7 a �p'ensotion Law:. �---�� S CONDITIONS _ i V ` . . ,,.. .:. . . .,� . , •.. . � ,,. Fe .-�• .. .,. � „.APP�icont �' - -�.,. .. . . .. . CITY .. ' .. -_ _ -- ZIP_ _ .." .._ .. • . .. . n 7T -- - - �- ---� -!OC . �.f..,L.....�._. ARCHITECT O . TEI. �,�� iaOTICE TO APPLICANT If ofter makmg'�Ihii Certificate o( � DISTRIQ. „ GROUP TYPE . ._ , FIRE PROCESSED BY Exemption;-you'should become•sub�e[h to-�the�Wo�kers' �-- ENGINEER HVfl Szan A� �� 4 - �J COeN�S/y`' �ZOp/�E Compensatlomprovisians af the Lobor Code,you must forlh- qppRE55 314 N. First, Arcadia 91006 .--��- --. �\-� -_ Y .N_. .. .f V . . _ . 'd wi�h-mmply with.such�pravisions or this�permit�shall be �-�--- 7E�, STATISTiCA�CtA55fjCATION ' APf. ONDO.•- ��Z deemed revoked:�.:..,.� � .',�„•� .....�..,�� . '�,..,,'• GOMRACTOR NO. ' ,,�(� IICENSED CONTRACTORS DECLARATION� •����-� �- �- � - - - �� � �- � -� ���, - - � QA55 NO.� ��� DWELC UNiTS�t � �� ��� �j� I hereby affirm Ihaf I am licensed under provisions of Chopter 9 ADDRE55 Same dS above . r�o. 510560 ��R�P � (tommencing with$et�ion 7000)of Division 3 of�he Business ond ___.. , __��� . � � '' � •; _.._ ...- . .. .._. _ . . . . Rofessions Code,ond m licensa is m full force and effed. Citt QA55 � � � ' � ' ��' '"' '-� ' ` '-'y —'' , . . . . BK. vG. ALIDATION- . Y . ,. 510560 : , B ..'�� SQ.FT..LS3S- NO.OF __•L . NO.OF ..1 ._ . ...CHECK • „ Litense�vmber� Lrc.Closs' S12E STORIES FAMItIES ONE � , , , . "� � �" . VALUATION ' � � `�'• �' "THE'ANDEN GROUP�'� �� J�H�HJ�, "' DESCRIPTIONOFWORK Sin le-Famil � �� � '�-� � � ��� � -� �� -� �-�� � ���� � � Contradar Dale " �� NEW . . ADD � S ��HO9 ' , : �I om exempt under Sec. ...._.. .. . . . ._ ... _ . . ._. ......_..❑ _ _.. ... .. . _ ._-- . . . ... . . . . AITER . � . . ..,� - •� ' �. �-..: ,.. . •�� e.aa.c.fo�ihis��asa� SLAB ONLY _ REPAIR ❑ s - --._.__..--J _. ......__ - ---- .._'_. ......_... ..........._...._. .. Dofe:...._._.....,. � USE OF DEMOL ❑ �� ' . ... . �O 7.Z 3,� � . E%ISTING BLDG. . . � _ .. ... • __. .. " . ..-.Signafufa . . . ........ ... ... .. ... "-'.. . APRIC/�NT TEL. FINAL /�/ ' ' OWNER-BUILDER DECLARATION � . ��� � � � �� ... vRINT NO. �DATE...`� / .`�'`J.._ ���. .... .:. .._-,...�..... ....___ ... . �� -I he�eby aiiirm that I am exempt from Ihe Conlractor's License ADDRESS SHID2 2S ahove � •, �• ,. I •�•7(6 2 5 �w for the following reason(Section 7031.5,B�siness and FINAL�,/J�,C� � � 1,fessions CodeJ: ....._. . -.--. '_----. ....-_'_-._ . Prte eNi � BY //'"� ' � - --- - � .LJ.. . . _ BUILDING �:��, `,� s ! e 7.�,.[5.� . I, as owner of the properly, or my employees wilh ADDRE55 �' � wages ds their sole compensalion,will do Ihe work and ���TM , � - •� -; �` � !'� _$7 �a� 7 the slr�clure is nol infended or oifered for sale(Secrion -, ' � �7044,Business and Professions Code).-� -� ---� '�''- MovwG-' '��� - �- � -- -- -� TEt:- ---- �- - � - -- -��- - - i � ���- - � , CONTRACTOR NO. ' �� `- :' ' 1,as owner of the property,am eatlusively toMrocling � � - ��! � ! ,� �' ; _�, ❑-- ' ' .-' - -... '. . _ i_ 1_ .� . -' - '-'-'- �w�th Itcensed contradors to consiroct tha projecr(Sec- qooae55 �ion 7044,Business ond Professions Code). ' i � . . ...-- '. . . .__'_' .REOUIRED_. TO1AL SETBACK FR M . XI .. ........._..._..._.... .. ' ___.._.._; ....__' _ _..._ CONSTRUCTION LENDING AGENCY"-� �--���� SET BACK � YARD �HWY- " PROP.LINE WIDTH ' --���, I hereby affirm�hot ihere is a canstrocrion lending agency for fkONi � "- �� � �' ' . , -Ihe per{ormanca of Ihe work�for which this permit is issoed --- r.L -- .... .. _ _.._.._ .. _.. _.,... .. _ . . _------.-_- _.-__._ ;--__.__.._.....__.._...._.._...--- (Sec.3097.Civ.C.). SIDE , � �• � • � _' `_.___.__. .. .__ _"_____.____.____'_ -_.- P.L. ..__ __. _. ' Lender's Nama Ci Yi}�Anl[ • ' P.C.Pee f�' - .. . ... Permii Fee �6 3.��]rj -- LDMA Ref.B ' ....._....'_'� __ ..... . :..i� _."' '._.. . . . . . .. . .'_'_.___._. _._-_ ._....... .. . . __ _ Lender's Address /yfy(y C- F7 O�PL� T -Q ����1 � �� "�� . . . .1 certify that I have read this opplico�ion and stole.thot.the ._._ . . _ . _._ ._. . ... . ._ issoa�ceFee 1�.�50 � � ioMAP/CX �' �-�- � ��������� ---._ .'-. ._'.._ :..__ _. _ - .-" abova info tion is correU.I agree fo comply with all County ' Invesiigation Fee � � .ordinan nd Stafa laws reloling to building constroction, ToMI Fee �- � ' �' � ' � �--. - .. __.._. ... . 74.25 - ��verm:s.. -- ---- -------___.. ___._ ond h e authorize represenlatives af this County to enter �- . upo h o ntioned property for inspec�ion �rposee. ' - - .,.- -- --. _/�. .. . �....__ . .. . .. . . - -' .... . _. . ._. .. . . ...... ."-_. _— _ ' ..._ ..'-_-'.-. '- ' X SEE REVERSE FOR EX►LANATORY UNGUAGE , I !� � _ .._."Sigrwivre oh pp�con�or Agent- . .-. — e ._ �.. _..'_' ' ._'_.'__ . . _ .. ' . ` _ .. .. . .QQ I ,�_ � . . _ ; ',�- .,�_ .G� a � °' '� _.�1,�--, �.� �' 4 c� `? 'C'� y �.' 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