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HomeMy WebLinkAbout0722A (4) �� :� .. . . . .... .....i ......�.... ,..... .� _.-.�., . _..�... . .. �... ... ,.. , , ......., �. c_... . .. � WCJRK�RS'COMPENSA�1"tON DECLARATION � `� . . � �" � ' ="� '� � y.. „-,: ,,;. :. ._ .... �^yyyy���_ � ., .. , . _ ._. _._... ... A �.._.._.-... .._ ^• � I hereb��afRrm t�hat„I haye a,cetf�c,ate of Sonsenf_to,self . . ����������� ��� ��������� ������ � y nsure or o ce hf caie of Workers Compensahon Insuronce, . 'or d 2ertif"ed mpy iRereof(Sec.3800,�Lab.C.} �� � � � -� ��'. ' . - ..---__ .�,... _...._..„, ��„ „.r ..,+A -i�- : � �� _ . 7�WC005-279-0016 Nationwide 3/C . COUNTY OF LOS ANGELES BUILDING AND BAFETY P�olicy o. � . .� Company ... . : . .'... .. . ... . _:. Certified copy is here6y�furnished. � � ��R Ap���CA�t T�������� ���'• ' -' BUILDING ADDRESS � 533.D012 Court . PY,. . . Y .9,,.. . . _ .._..___ ,_._._._.___._.,_._,. . _ ❑. P � �.. . . peC .,.__._ Bu1LD/NG .. . . ... . .._ ... . . . . ._.. . .._.... .. Cert f ed co s filed wiih the count �bmldm n3 ��on de artmvnt. " ADDRE55 533 Dole Conrt .:, . . . _ _ :: _...__.� _ . __....._.._�_ o6re -7/8/87., App�;�a„r THE ANDF�I,GROUP oTv Diarnond Bar 21P 9I765 ��AiiTv Diamond Bar_ '�C�ERTIFICAJE OF EXE�ti1PTION FROM WORKERS' "� � � NO OF BLDGS . NEAREST � ', - � � � � , � -- _ . �"' ' � GOMPENSATION'INSl1RANCE �- �� 9ZE OF I.OT NOW ON LO7 � CROSS ST Diamond�Bar B,Iyd:/Golden $PY1RgS (This�sec`tion rteed-��nor be-completed if ihe permit is for one -�� �� � � nSSESSOR �' �,"� � � hund ed.dollars($100)or les5) TRACT LF2,5 � BLOCK LOT NO. MAP BOOK�� ' PAGE PARCEL , . . � TEL. .._ ,.�., USE ZONE� MAP. . /.�_ . . . f certify�"that n fhe°pe forman'ce of rhe w ' owNeR THE ANDEN'GROUP NO. 967-95 1 work for hich this � NO. /� "�� � 6 perm t�s'ssued,'I shall not employ a�y person m any manner - SPECIAL � � -- � � - so�as to 6etome'subjett to the Workers'Compensation�Laws. - AD�RE55 P.�..� $OX�3329 _ , CONoiONS �Q �`� ���le � A �`icant�, ..,..�:.. ,.:..: . CITV . ''� ZIP. ... _ ' - � .. � z.. .,. Exem iio - pP ARCHRECT OR - TEL � DISTRICT,_, GROUP iVPE� ' .... . .FIRE PROCESS�D.BY � vOTICE'TO APPLICANT. If, after making this Cerlificpte of ENGINEER �D3V2. $ZBri�j A� NC�}4'S-�+Q�3. . - CONST. ZOyE �V p n, you should 6ecome sobjed'to�the�Workers' � � � � -- -- �- -� --� � �--� --�� �\ .yrt,� /� \t,� rn i1 Compeh'sahon provisio�rof�Khe Labor'Code,you mus4 forth- qDDRESS 314 N. Fi t T 3C113 1 . �`�-- +`� :�" � � J-�`�� '�`�`a�� .y wiSh,compiy with.such provisions or this,permit shall,be _ �� � � �����--� - ---- �--��--�� ���.-�---�-------�• , .. deemed�revoked.,,.,; , . . . CONTRACTOR �H�S' .L�Dl,''N CiR�TJ�. NEO. STATISTICAI CLASSIFICATION � APT. CONDO. ,_z , � ' �... . .. LICENSED CONTRACTORS DECLAR�ATION� . ' � � -� -� � - - - � �� ' ��� tIC � � �- CLASS NQ � � DWELL UNITS co reby affirm ihot I pm licensed under provisions of Chapter 9 ADDRE55 $aI118 3S above NO.Jr I-0560 � SEV✓ER MAP �� � (h mmenung witfi�Sectwn 7000)of Division�3 of ihe Business,and .,._._.. � -. . . � �'-�I,IC. � ��� � -������ � . Professions Code,and my I cense is-in,full force and effe�L � CITY - CLASS gK �; - � VAUDATION - '. ,_. ... .... . . . � ' SQ.FT. � NO.aF NO OF CHECK � License Nvm6er `'S10$6� Lia Cldss B - si� l sroei�.s FnMwEs oNe _ _ , ..-. � _ ,,. .,. . - -.. . ... ._. . . VALUATION._ _.. . .. .. . . :� THE ANDE'N UROUP J�8�S7 � DESCRIPTION�OF WORK 5111 12 FdIlll.�- � �-NEW � � ' Contiocibr Date ADD � S 7 r 2 H O ❑I am exempt under Sec � � � �--�� 462- SF � �a - , � - ' ' � SLAB ONLY "�TER B.&P.C.for this reason __.... . .. REPAIR ❑ ..s . . . . .. .. . - ��U%�,��i �.. .,. . ...... ._.. �,. USE OF � . . Date: .. � .. . .. EXIS7ING BLDG. . .. .. . ... ' DEMOL ❑ . .. .. . ..��s..�....a._s.��_. . s�yr,amre _ _ aPrucnNr THE AN➢EN GROUP No _ _ ,_ FlNA� � OWNER-BUILbER DECLARATION . . .Pkwi) .....,_. . ....._.._ . .. .. . . . DATE .�-�:� ��5�.. .... ....� o s']fj.2�.....,. .I here6y affirm that.l am exempt from ihe Contractor's License � - �, . �,^�"'^�.w for rhe following retlson-(Sechoh 7031 5, Bosiness�and ADDRE55 52SR0 dS �8})OV2 � � FINA'L � ����� " � � a ��z��'�(�.��j� . ,,DfessionsCode)r�... ..,. . ,......, ......,_. _. T . .. .. . ,.. ..._._...__. __.:.....-„-,.-..,......�._._._�W By �, . :� . . '� 1, as owner of the property, or my employees with A�DRIESS . , . .. � � �~ �a� Q�' � ���.�7 . , .... . . . . ._. ..... . . .. . �.�. -..� .. . wages as�iheir sole compenspfion,will do the work and , �--°� ' ' ` , :� � : - the siructure is not intended or offered for sale(Section LOCALITY .„,,, ..,.. , - � -7044;��BusinessandProfessions��CodeJ: �-- - '- MOVING� � -- �- 7EL. � � - � �. � ' -`� �� ��� �� I,as owner of the property,am exclusively contracting CONTRACTOR NO �- !t-+_�� �� � �� � '-�- �- � _.. . _.:.__,1 �� ---with licensed-conirattors to construd ihe projecY(Sec- '� � pDDRE55 � � � tion 7044,Business and Professions Code). � � _". . . ......CONSTRUGTIOK�LENDING�A'GENCY .". ...-. .�... SET�BACK � VARD HWY TOTAPROPLINE ....�..� � WIDTFi ... .. . . . .. .. . . . . . _ I hereby affirm 1haT ihere is a construction lendi.ng agency for FRONT - ' � ` the performance of)he work�for which this-pevmit is�issued - -�P.L� ��` '�� --� -� � � � . (Sec.3097,Civ.C.). � SIDE . � � P.L .... .._._._ � Citibank e Lender's Name � � -�� - ' - � ���� LDMA Ref.# " � �` ""'" '" ' 444 S. Flower'. L.Ae 90071 PQFee$ Pe�mi�Fee 63.75 - ' - Lender'sAddress � � � - � �� � - �- � w I cer(ify Jhpf I have read Ihis application and state tha�the -.- - Issuonce Fee 1�.rJ�� � �tDMA P/C k �-- � �-� �� � � above infor fion is correci.I agree to comply wifh all County �� Investigatioo Fee � . � . m ordinanc d Stote laws_relating ro�buildmg consiruc(ion, ,.. �TotalFee- 74.ZrJ -LDMA�Perm�# -�- - � � - -� � and her uthorize represe�tatives of this County-to enter � � < upon f � ve � ned property for inspetfion urposes. . . . ..... . '::. ...._,........ . ........_ ,.,,.,�..,.. . . .,_,.,:. �....,. -.. �„ .. . .. . . . m n, a � SEE REVERSE FOR EXPLANATORY LANGUAGE � --.....Signoture� App iconh or Agenf . . �-� . .. . . . . . . . � . ._ . .�- .O', � PLANS TO APPLICANT �-iNS�ECiOR'S NOTES � OWNiiR-BUiLDLR DECI.AIj,ATIO�N - � � � . _ . .. , . , . I hereby affirm ihat 1 am ezempt from the Contsactor's To: '-" '� Retvmed '� � .,� �� - ���License Law�far,the'follow ny reasan (Sec. �7D31:�5) � � � �- � � � Approved ' '� � � IIusiness axd Prpfessions Code:Any,csty.or rouniy wbicb. No. Da}e - No: �ba}e �"'��� � ��+-� '�� ' ." -'� � i.,� '? requires¢pernsit to co+r.struct,ulter,improve,.demolisb, �� , _ ��._.� � � - � . � - or rep¢ir atty stracture,prior�to its issuance,ako reguires � ... . . � � . . . � the applicaxt fnr sud�pernzit to Jile a signed�statemext ����� . . thud he is licexsed pursu¢nt ta tl�e provFsi�ns,of tbe Con-. � � � � � , - -- tractor's I,icexse L¢w(Cbapaer 9J(commencing with Sec- . ._. .:_._.. l .f. -�F. f -. ____ _._. � , - . tion 7U00 o I�ivrsio �3 o the Business 4n¢:Pr%rsions . � � . . � �- ���`��� - �-'"�.� - CodeJ or lliat 5e u�exe»zpt therefrom and the bastt for tfie� � - alZeged exempt'¢n.Anv�via[piion of SecMon 7031.5 Ay � .:-.' :3i�' RBqujred. � � �." . . .� . an ¢ licani nr u ermit su ecas the a luaxt to a cimtil . Approvals � �Dafe Received�. . � .Y PP f 1' �l PP Yes No or Appro'ved.- � , � pex¢Ity of not rnnre tban five 5undred.dollars/$500J./:� ..._ . , .. . . .. . ��__. „ . � � � �� � ❑ I,as owner of tne property,or my employees�with Water Certificate � � ��- � ��-- � ��� - � . . . -.:-.� . , =-:. .-.�.... - �wages as iheir sole compensation,will do the work,and -� � � ' � the st ucture is not intended o,of#eted for sale($ec 7044) Health Department. . _._. - ... . .....-. _ .,... ,...-- .:-.-:�. _ .�... _ .. �._ . . ���.Busxness aiad Projessions Code:Tbe�'oatracaors License Lam does not apply to an oumer nf properdy who buikls., ' Fire.Departmem _ � . � --�� � -� -���-� - ,�-�- - � or�mprovestbe evn,andwhodoessurbu�nrkhimselJ � . ._.._._ ._.... � ..-.` ,' ...,,:.: _.:.;.. . .. . . .. .. .;.. � tfiraugb bis,.own employees,proveded tbat such'.dn. '� Groding � . , prnvemends arP��eot inleteded or ffered for sdle. Ij,. � � �� � - hawever,the buiJdixg�nr impr.avemenE is�sold widfiinane ,:.�� Geologi[al .......'�. . . - . .. . ...-. ,; �~... .... ...�� ,�'�� �.: �� .�-�ye¢r�of-romp[etinn, the nwner-$uild¢r�will bave tbe � _ � -� - - . '-. - burden of proving tbat be dad not bufld or�impmne jor zhe ur ose o�sale. �� -��: Pedest�an Protection ,6.� �: . �` � � . .' 1' 1' / I � .. . . Fencel Cono ..... �, � ,,, :. .,,.�. .._.. , . ( ( py)� . � .. . �, " �`� � ' '' "� '"'"��" ' �- ` . �� ❑ I,as ownerbf ihe property,am ex<lusively contrac � � �ting'with licensed<oniroctors fo constiuct the project(Se<. Special Inspection'"� �' --��-�� �� � ��� � ��� - �� -- -� - �.��: , 7044)Busdiiess¢nd�Professaons Code:Tbe��ontrd<Eor's (Conc.)(Mosonry)(Weldingl - - •,;.- ___ ,,, , �,:, - = License Law does not apply to an ouner nf prn�erty who. . huilds or ln�yroves�thereon,and iiiho coneracEs,}nr such�� Lot Drainage � �. - � . .. .r ..:.�.._ .._ �.: p+'jecGt�mith a cotttractor(sf licerised puraiaant�to�tbe � .�-. � . . � . .Contractor's Ls'cense I,¢wJ.. ... . .. . . � '".:. Parking . �. , �. . ' " , . . . .. � . .. ._.. . . .._ _...�. � .. . � �. . . � �. . - � . ❑ I am exempt under Sec ,B.&P.C.for ihis � � . reason._.. . ..._ . ...._. ......_ . . . , . _.. . . . . .. .__Date .. . _ __.. . . ....., Owner._..... . .. . _ ...,... � ,.... Approvals Date Inspector's SignWure . .�� ._ �..:. . ...,... . . _.,. . : ,�:-. .:� INSPECTOR'S NOTES . .�_ . Localion— "� .. .���: . � . . (Set6ack&Yards) � � �� `� ... � ,' _. Foundations y� . - . . . _ . . . _.. � � _ .. ,. .. �.._ .. . .. Slab � . . � . .. ... . � . . _ . . . . . . . :.. . . . Prame . . . _ . . . .. . . . .. _ _ . . . .. . Energy Insulation ��� .. - .. .. � . . . . , . ... . . . . . Lath/Drywall—� ' __ .._... . . , ... . .. _ .. . - .;. . __..�. ... . _.._. ._.. . ..._ _... ,.. , .. Interior . . .._.. ._ ..._. .: ._. :,, � ';� .. - . . . Lath—Exterior � � . . . . ...�. . .... .. .. . - . . . .. .. . . .. . ... � . . ,. . .. . - . House Number— � � �� � - � � �� � . - �. Correci&Posted .� :. . , . . . . .... ._;,. ..,._ ..;. .r;, ::..�. . . .,._ Final—. _._ ... . . � " . . . . . . . . �.;._; :_. � .. �....�.. :... .._� �.;. ENer on Front � � � � . � � � - � � � - �` . . .. .. : � - . .,; .. . _... . . �..._ . ... . . . . .. . . .. . . ... . . .. � . _ . . .. . . . . . w. ... .. ., .. ._ , ,'w ` _ ' v .�. -z ,t..r� - . . . . , . . .._ . , .,t - .. . . . �,, x,, - �, .,. * .... . _,— :, a ... i :,,5.•