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HomeMy WebLinkAbout0825A (4) , , ; . _.. _ . _ �.__. ._ _ . _. , ' insure,or a cer��cme of Workers'Com eARATION . . . ?, , .:: . -.- . ._. ' . ., ._. ..; .:" -.- -, ..- .- ._.... . __._ . ' . . °'�°°Se°''°Se" . v.APPLICie►TIOT�J FOR -BU�ILDII'�G�PERMIT � I hereb� ofFirm that I hove o cerrifica�e,�soton Insurance � � v-WORK S COMPENSATION DECL ; . :or a certified coey�hereof(Set.3800.Lab.`C.� . .� .' , ._, .. ....., . . . _ . -.. ._ ..... .. ... .. _. � .i . � .. � ' 73wC005-279-0016 � � . 1/C COUNTY OF LOS ANGELES BUILDING AND SAFETY -' Vo ityNo. �Company Natio:iwide�� __ . � ` O, Certifiad copy�s hereby(umtshed. FOR APPLICANT TO FILL IN ! gui�oiN� � i _ _ r ooaess � t'� e ! � Ceitified copy Is filed wifh fhe county 6uilding inspec• . BUIIDING 1 -I� ro�depo.rme�r. - aooaess 24233 Gem P1ace i : ,., •, .: .. ;: , ,.. :..� --' -. _. ._. _ . � _.. . _ . _. .._ _ . . . .. . _ � _ - - Dare.,�. ..8-5-87 Applicani. THF.-AfIDFN�rROiiP� � CiTY zia . ..�..- iouuiTr� �Di'amond�!:. � ''�`'CERTIFICATE OF EXEMPTION FROM WORKERS'.=��'.'.° __. .... ..... ...•,.� .... ...'- `- -... .NO.OF B�UGS_ .�. ._ ....� NEAREST,.._...: _ __.....I..._- .' - ' �^����� '��COMPENSATION INSURANCE��� � -•- - SRE OF LOT � NOW ON LOT � -"� CROSS ST.. . � '" '"- �'"`-"� '-�"' '� (This section need nat be completed if the.peimif h for_one �-- _. . .. ' .39 __.�� ASSESSOR�. � � - . , . TRA[T� BIOCK�� - � LOT NO: 10.qp gppK' `. � � '� � PAGE - PARCEL . � P ndred dollcrs(EI00)or less.J,� . ., . � � � , . . ., , �_ EL . �P , . __.... OWNER_ _ ._..NO _ �. USE�O��. :; heertify tha�in the performance�of�ha woik�for which this � � � � � �� - ,I c . .� . . . � rmit is issuad,1 shall nol employ any�person in any monner .. , � .;. . . .. ......... . __. . -- . .____._ -$aoJ co`oinoNs l . � o so as�o becomc subjett�o the Workers'Compensation Laws. , no0Re5S� ° /"� 9 < aTr Covina.. na i ; _._ . _ .._,� _ � , . � - � U F fxem tion, ou�sho�ld'become sub'ect to ihe Wof ARCHIiECT OR te ' " APPlicont ' - (� j ..JTICE TO'APPLICANT: If,�oNer makin �bis Certifica�e of �•� �� � TE�' � �• ' � DISTRICi GROuv TYCE�� FleE PROCE55ED Bv ; P Y I kers' . -.. ENGINEER 'D3V0 Szan AIA� r+o.44 - 7 � �� �-� ���-- ��r. --- �� zoNe- - - � � —�ComPensolion provisions of Ihe La6or Code,you musr forth- ApoaEu � 314'N..F1YSt�� Arcadia��91006 -� �� �d ' � � W winc �vmply with such..provis ons ar,this pe�mil sholt be ...:_ .._ _ . _ .._ --�qF� �� - ATISTICAL CtA55 i N nPi a ', deemed re�oked. , , ., , .,...'.. , • . conrranaoa THE ANDEN GROUP. �, i . � ST IFICATO NDO. � LICENSED CONTRACTORS DECLARATION . _.;_. ......_._..-. ._. _.� . . . . . _..LIC.�- : ..; -CLA55 NO.�-'� --ONIEtt.VNiTS - . .... — ' I hereby offirm that I am licensed undar provisions o(Choprer 9 i AD�RE55 As� above'� � No. �510560 . �R�P Z (mmmencing with Section 7000)of Dnisian 3 of ihe Bvsineu and _ . .. .__ .. . ...... . .. ...... _.UC. � . . . . ' - . Pro(essions Code,and my license is in full lorce and eHecL �� CITV � �� ���� CIASS �B � - . ' .. ._ . .. . ..� ,� . ,. . ... . , �, ... . '... BK...�_.PG.. ,_ ___., _ ' . � -�VALIDATION-- 50 fT. NO.OF NO OF . � CHECK+, - . LlcenseNumbar 510560� ':uc:[ias: � B� ' `�-`�" srze-1535--sToeier --2 � Fn�:+wes- 1�-• -�oNe � � . � . VALUATION � �- � � � . .... .. , -. 418 SF ' � s� . .. - . ; _ . _ . Confrotlor '`THE ANDEPI GRO��e � �-S-R]�""'-�--� DESGRIPTION OF WORK - 1 A D - �S O9 � . " _ �Iamexemptunder5ec.'.. � �--.-.. �. ALTER�' .� , .I' '.. ... �d�25A .. �'� 8.8RC.for this-reaion . . ,, �...� �.. . � $Lt�B��NI,Y� ' REPAtR,_ • --S_. .:. ' _...._._. �, � _ ,._ __ . _...- ��• � � • • � _ . .._ � .. ......'Date: ........ ... . � . USE OF -. 1 DEMIX . � . EXISTING BIDG. � . ' � . . . _.;. APFLICANT . __..... .. ._ . . . .. ..TEL .. .,. _... . .' i a l I.'.2 JG ._..Sigrwture' .. ... . . . .._._... ._._ '_ �.. , .FINAI �.�� � OWNER-BVILDER DECIARATION � . � veirlr NO ,OATE.y '�� '� �� � .I here6y affirm that I am axemp�from the Contractor's license �"'""' - �-� � --� '-�' " � .-""- '-� � - � ';'"� ` " ,� ������ '�� �7�2 S��" �w/or Ihe following reoson'(Secfion 7031.5,Business ond " AaDRESS t�.5 8bOVe � - � � FINAL '�� �-•�� � o(essions Code). ....__._ ...._._.._. _._....... .._. R ._ .. . . . _..... . �. . . .�. . By �ils�j , ' _ 0'�� 7`�$7.. ' � BUILDING � � � 1, as ownar of the property, or my employees with � ADORE55 ' ...�- wages as Iheir sole compansotion,will do Ihe wark and .. -". .'..-. . ........ ._. ..._ _.. , .., . ... - " -. 4�.. . '- '• . .. ' ,..'. iocnim � ' ., ; , tha struc�ure is nm intended or offered for sale(Section � � � � -� � � � �-7044,Businms and Professions Coda). �� - � -�-��� MOVING � � � ���---�-- �-• �TEI. I .. �,. . - . _ . .__. . . ... _ ' . � O 1,os ownar of the properfy,am exclusively coNradmg CONiRnCiOa � .NQ � - , I. . ' . � '�with lieensed mmractors to const�uct tha prolecf(Sac- ..._.. . �.. -. ---�-- ..- .. -.-.. . .. ..:... .. '� . . ..-.`. '-!.__.. ._. : ._ . . _ . lion 7044,Business und Professlons Coda). ADDR£55'� � . ,_.___... REQUIRf� , yARD HWY- ..10TAl5EiBA K � : - 'CONSTRUCTION LENDING AGENCY '-- ' '�- ' '�7 gq�K � ' vROP.UNE '�" wiDTH �-" ' ""' "-" "'" ' - " ' " 1 hereby ofiirm fhat thera is a con:frudion lending agency lor �� faONi � �� - � . � ' ' � ��- � ��� � . Ihe pedormonce of Ihe work for which-this permit Is issued :.._:. ._p.i_.. .�_ � �_. .' '�, , . _ . . . . .__ . . . . ... . .. _. . . , ($ec.30ff7.Civ.C.)-. � " SIDE . � . . ' . . . , . . ... _ ' � P.L. ' ' .. , I. .. � . �Lender'sName_ � C�t3b.3tik�� �-��� "`�" -�-` � � I .. .. � � LDMA Ref.N . I: . ..�_.. . 4 - . .. � . ... ... . .'-- G C.Fae i . -...,. . : Permn Fee . . Lender'aAddress /�L����S Flower;-.1�A�qnm1 . . � ������� �- � � I.certify�ha�I hava raod this applico�ion and a�a�e tbat.the .. _ ._ ._ . -- -. ise�an<e Fee� lO.50 �- iDAAA P/C M. ���- ��- �.:����� � .. . _ - ._ ,. . above informafion is correcL I agree to comply wilh all County� lnvesrigation Fee � . � � � $ _.ordinances State laws rela�ing fo building construnion. � _-.._-_ ._.._ , to�al Fse- _.74�ZS � IDMq Perm.A..�...__ ._ . .. . ___ - _.. .. . . . ,..�... .... _..�� ..__ +,. _.� . 2 and here Ihorize rePresenlafivee of this Counry to enfa� - S upon th a ntioned ro erl for ins etfion ur ses. , SEE RFVERSE fON EXPIANATORY LANGUAGE�� ��I� P P Y P Po - - .. - --. . ..._.. ... . . . ..., S . . . Signature o{Applicanr or�r....... _. .._ �e. . . . �. ... .. ... . . ... .._. . .,_ .. �_ .. _ . , . . . . .. .. .. - ... .. . _... .._ . . i � OI\1 K ItUil DI R DI l 1 AH 11 IO� �`1 � PlANS TO APPLICANT � INSPECTOR'S NOTES bt0 + � J . I � r' �" � ! . _ { {�t ,. � I h cby n f rm ihoi�o e e �pi fro�the Con�a-�or'S F I.j To: L �:�ti e..t,:i>���i, �2eturn d:.L.-.'; t��:�W.,. b� �..-t• fu tf�L}�..7�L �4''"�.r���e.��.(t'••t�ir��sl 1� �-li�e,ie^Eo��to� i1 e`Fol{o r9.,�coso .. (Src �G�1�) I. APProved . •:'lfusrnrsa dlrf � nc(.d�:lin<<itt r mnh���(od� I . u � `�i,�i�..,lf: 23.?�',��r 2f'�!RO!'Tb;`.).7J 'J�.[ rr u�r u �ermiel rinslr �r h r, e�'1 � ... 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