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HomeMy WebLinkAbout1064A 1065A .. . .. . _ _ ._._...------..._....----.. . ..._._ _._._._. _ _ . _ _.. .._ . WORKERS'COMPENSATION DECLARAiION ' -.; -.::,::.... m'�'- � "",-'. „ . .._.-.-_.�__._.._ .. ,.-.._.. ..._ � � �.�_. . . . .. _ ..._�____._ . � , -- ' • . . . . .. ., � .. I hereby a(firm�thot I hava a certi(icote Of�consent fo se11 APPLICATION FOR;BUIL'DI(�G �PERMIT-- �- �� insu�e,or a te�tiiicate of Woikers'Compensation Ins�rance, _.. . ._ ... _. _ . . ._,. or o ceru ie copy t ereo �Sec.3800,tob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � ' ,.;. ., PouryNa3WC005=2�7o�,��QT6 'Na.tioriwide 60 3 Car -_ -- -- -... - . --- . . . . � �Cerlified co is hereb fumished.• BU�IDING 7��1 � I, � , PY Y ' FOR APPLICANT TO FILL IN ADDRESS � D �'Cer�itled copy is filed with tha tounry building inspeo- � BUiIDiNG liori department. ' � � � - '� ADDRE55 7� N. �2��'1e1�''AOC� �1V0 . . Da�e�'H-1-SF)�... Applicont_TE'��ANDE�iI��GR7UP CiTY Diamorr3 Bar z�r 91765 ' �W,un. Diamond Bar ' � '�� '� �CERTIFICATE OF EXEMPTION FROM WORKERS'� � "� � "-- ""-"-"'--�- - -`"�---'"��OF eLDGS.� �-� -- ���. nrEAREST- _.. ... . .. � __:. .. ........ . ............ .. _._ � ' � COMPENSATION INSURANCE � ' •� � SRE OF lOT NOw ON lOT cRoss sT. . H'a ,.. ... (This seclion need nol be tompleled if the permit�s rero�a - � �--�-35761 --� --- � --- - -�-- - -----� ^u�oR . - - `-� - ` ' ' hundred dollors(5100)or less.) . -. . � TRA - BLOGK Mqp gppl( ��� � � PAGE PARCEL , . ' , - - owniea- � ADIDEN G � -No.967= 41 ' �"''P /� ' USE 20NE i certify that in the performonce of the work,for which�this r � �. 3-3 - � � �� permit is issoed,I shall not employ ony penon in ony manner .. P.Q.$Q$ 3329 ' - SPECInL � -� --- - � - - � -'6 � ". AD�RE55.. ... ._' "_.'__'..__... so as to become subjecf'to the Workeri Compensa�ion L'aws. � - - ' �1X� CONDITION$ - �u �,re, nppl�cant. ....: , ., . - aTr_-- Covir�- - - ---z�e. _.91722. _,. ...._- -- -- . - __ , � . _ TICE TO APPLICANT: If, aher moking this Cedifimte of ARCHI7ECtOR TEL , 0 TRICT_ GROUP� IYPE � FlRE PROCESSEDBY__ �� �emption, you shouid become subjetl lo�the Wo�ke�i' " -� ENGWEER �clV@ $Zd AT11 No.445-4�73 . � �pN-'"�- - -- "2Oy� G I Com ensotion rovisions of the Lo6or Cade,� �p � VY w P P yeu must forth- • • . .... ....._ .1\'3 _-.l� � l �a with com I wilh s�ch rovisions or this ..,_ ADDRE55 � -. .. ._ . p y p permil sholl be � � � y deemed revoked.; • -�� CONTRACTOR �A1�IDIN GRCIUP TE�' $TATISTICAL MSSIFICATION � � APT. CONDp. Z . ��. � .. .:. N�. � ) ��----- -- - -� �I LICENSED CONTRACTORS DECLARATION��^. �- �- --- �� �- �- - �-��- -- ---- -i��,- �.. - - . �Qa55 NO. �� DYVELL UNITS . ' I hereby aHirm fhal I am litensed under provisions of Chap�er 9 aDDRESS AS e1}70VE r,o. 371580 (mmmencing with Section 7000)of Division 3 of the Businessand _.___ .___. .._ __ __._. � ��R�P ' � '�' � _ . . .. . _..._.�IC. .__'$ "'_"' . . Professions Code,and my license is In full force and effetl. Cltt nq55 � - -------- -�-�---- �- - � -- -- . . . � . . ' BK. pG. , : . • ..VALIDATION ; '371580 ' $ - . si.EFr.2375.-nro.oF , No.oF ._... cHea , ; li[ense Number �lic.Closs ' STORiES� � � ��� FPMILIES �-� � -ONE , - .. . � , , . . . ., _.VALUATION --- -- -- • - .-- --- �- . -�IE ANDEDI GI�UP�pQ�a �H�Z�HF7�� - �ESCRIPIION OF WORK Si le famiL ----- "� - 10 9 6 00 , � co��.o��o. ADD � s ' . : ' :^1 0 6 4 A • . . . ..._ _ .. �I am exampt under Sec. -. �... - - �-"--'---�- --.___ . .' . . .. . ALTER � � � ,',� �s e • •`�� � - ' "' '._' - . . .... . . . 0.8P.C.forthisreason �--�- ---:- .-... .- '-----�----- '- --- --.. ---- REPA�R.a �--:... . . _._. _... ' . . . ._._. _.___. . ' � USEOF : � . ' � ����.69 . . .-..-Date: " EXISTING BLDC. DEMOL ' '_'.'.__ ' . . .._ � APPLICANT TEI. . -.._.��m_.. ..-.--4 2 . .. ._ :"" _ _"'___. _ _' ' 5gnatvre -- gq-� j�sj Ggf�[]p FINAI ��4.b � OWNER-BUIIDER�ECLARATION ���'�T7 NO. , -7'�-� � : . _.DATE"Z'--.rJ_..$�_'- '..__. .__ ...'_-•_ .-"..._.. -�I hereby aifirm Ihat I am e�empt from Ihe Coniroctor's licensa Ve - O A 2 2",8 6 � � �aw for�he fallowing reasom(Section 70.31.5,Bminess ond aooRE55 flNAi" �"' � ____... ........ �fessions Code):. . . _ ._ ._ -�- Pk EN - _�By . ....... . . . . .__�, - � - - ���_`�';��'�_- ' i I, as owner of the proparty, or my employees with _ ADDRESS - � �� ••\^".1• ! '� I • '._� +. - .� :-.�. woges as their sole compensation,will do the work and ' � � � " fhe siroctvre is not intended ar aifered for saie(SeUion ����TY�=�� �"` '�' ^+ �•� '�•�> .•`.� �� '� '�'1 C Q 5.A,. �' ; : -._..._ . , . ._...._.. - - : .._. .�7044.Business and Professions Code):..... . .... MOViNG- '�� � � ��-` ' --�.,•.TEU - -- ��- • � -'- CONTRAROR NO: i ' {;a • • • �'�.,,:-� I,as owner of the p�operty,om eaclusively contracting � .�-�withlicensedtontroUorslownsiroctthaproject�Sec- "" � ----"--� ���-1---� �-'--"-' --�----"--�-� ---- -- -� --'-'---- -'-'...... ... _ _.._..--_ --_ � ADDRE55 � " (`� �: , I °S I:�C O . rion 7044,Buziness and Professions Code. � ' _� � „ . . � _ ' __ .REOUIREO . ..TOiAlSEiBACKFR M.. . I . _... ._. 'a�_ �'��j�_-. `�`��'��C;'.._ �_ � � "- �- CONSTRUCTION IENDING AGENCY � --�- 5eT enCK �ARD HWY� pgOP.UNE WIDTH . '' % �� . • 'b 7.i.O O c=i'� I hereby a(firm that�here is a wnstrucHon lending agency for FRONi ,..�;:�.'^•l:.i'. ;i„'.,':'-•; , " � � � - •. •• the performance of ihe work far which this permit�irissued ----- �P.L:"'--' -- - - -- ----- -----'-- .-..- - __.. . . .- ' -'. . _. k...._ - --Q&2 .. (Sec.3097,Civ.C.). SIDE -��'- �` �� ��8 6�� , � - ' - -Continental�Illirnis-..� r.�.__ . • °�� �; ,._ • ;.... r - - --- .•--,.,.� . - - �-- - - - . ... . _ „ . .... > Lender's Name -- --". . .' ��i -� '� ... 231 S: L�33112 CI11C3 IL60693 v.e.F�e s 3 34.6 9-- re.m��Fee-5 6 2-:5 0_. .. . wnva ee�.x �.,�.. .�;; � d _. . ._... � . _.. = Lender's Address I � .�, . .' .I certify fhat I have read this app�ication and sbte thm tha ---- _ _ .. ---'_--.- issuo�ce Fee ... - -- --'� LDMn PiC k � `�:-`: . . .._.._ ---..._---__ �... .:,...._._-�--- ��� { abova Info�malion is torrect I agrea to comply wi�h oll Coonty invesrigaiion fee � � ; _ordinonces a �ote iaws�eiou�9�o bond��9 co�s���cnon, .._ . 573�.0�--�- ' �' �� � ____. .. ._... ... " _'.'." Total Fee...__' � lDA1A Pcrm.N. __..._._ __._ _...._..... _.. ....._ . . ._.. .� � and hereb orize represeMatives of this Covnty to enter , , ( upon th b • tianed propeny for inspec�io �rposes. LD A $75 � 35 � , __ . .. . --. .- '-....._ .... _ . ._.. ...-.._ - • / M - ---. ..-- -- - o � � ��(p SEE REVERSE FOR E%PMNATORY IANGUAGE ' , ' ..... .. ..Signo��reo ApplimnrorAgenr. _ _._- `_ Dore ... .. . .. ........... .. ._ .__...."'__....__'..._.._____ _'. _ .. _ _. __ �.__ ...'.... .. .._ _..._.. ... __. ..__ .p.� .. . __. Z ��'. . � — - o .. � ' .T- ..�_. .�G- �'�;.. < r T-p_. -G'1 "p� � ' �p l� '�: N ' � o nv m p �i a 0 0 �0 � �, a ,s � rn � T m n � � � O ..CJ�� � � � , �� �� � 'n O -. r 7 .,. _ ' n 4 � �. 9� rn T !1 Z s � � fl Cl 7 ��. 9 , m 7 j. C l 7 � O � 9 O O ,0 3 n < � � p �� T N� IG N O �� 9� � p �': � � � N ,� �`i .'� m j Z �` ''� N N { i � p;. � n .. �� � � � M ' -o Q'� lp O C Q C � T �� 0 Q M �: y.0 'Y . ' �` ' . D 3 �ry � � p �' . � �L i� ? � - ��' � N N � cD ' 1 aI a - ' 2 O � o � a � -� l r d � � p '. '� � 1=r:. M q 'r, �' � I � i � A t`' .,�J'� O ' "",.C� � . .. • a O �� Z ♦ � ,:� 2 � • e ,a „� ' j v�. 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