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HomeMy WebLinkAbout0794A (4) J .._ ... e.
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' ' WORK�dS'COMPENSATIONDECLARATION ." . .._..._ � .."..."'I -- '--.. ....... ..... ..... .........
! .., . . .. , ..-__ �....-..._..._ - '_"" : . ' � � ' - � �_- . ..
I hereby affirm that 1 have a cenifiwte of mnsent�0 3elf . + C��I�� �
insure,oracertificoteofWorkers'Compensation��,�.o��e, : � APPLICATIO�N��: � �
' or�6tertifiedcopYthereof�Sec:3800.La6.C) .�'�. . . . _...ZIC. .. ',.. .-.... . .._ .FOR BU1L'DING���P., �
� , ...
��W���5_279,0�� , �. COUNTY.OF LOS ANGELES BUILbING AND SAFETY
o pany Nati nnu.i Aa
O Certified copy is hereby furnishad. � � � FOR APPLICANT TO FILL W � Bu��D�NG .I . I
ADDRESS
� �Cerlified eopy�ia filed wNh�Ihe county building'inspea'. ' BUILDING - � I
tiondepartmeM;' ' � ADDRE55 24254 Gem .Place
�. . . . �., ,_ ...,',,� :�' r . . '
. . .......... . . . ' _'_'_. . .___ ..._._ _ _ . . ...__ ._ ... ... .. . . ..,.,. . _..- .;.. ,
Dc� . . . . ..� .. .. ... . .. . . ... ....
„ 8/S/87,.�.APPi;�o,,, •THE ANDEN GROUP arrDiamond Bar z�v91765 �ocnurvDiamond Bar �
��I"� CERTIFICATE OF EXEMPTION FROM WORKERS'�'^` � �-`�' � � � '��--"'-'"-` - NO.OF BLDGS. -- � �� ..:_ NEAR�Si �
' � '" 'COMPENSATION INSURANCE-�� . - . � SIZE OF tOT - NOW ON lOT � CRO55 S7 D1'HIIIOIICl"BdL'.��B 1 VCI--&-GO 1 H@II�-S�J ings
.,..:.,.,. .
� huis section need not be tompleled if tha permit Is for one .._._... ..- .� .... ...... -. ' . ' ASSESSOR � ,.--.�.... �,.., . .
Th TRAR�I L rJ H O BLOCK L0T NO. � 4 2
ndred dollon(5100)or less.).-�,... .,-. � NJ�v BOOK '���� '� �: PAGE PARCFL
ao ostt betome a�b ect to he WorkeneCom�ensan manner � -..TE`, .._, ; ...: u��(�Ov� O� ' ' ' �:. ,
j � . . � . .. . _'_ OWNER �- .. .
�� y, p work for whieh this
rmil is Iswed,I shall not employ any p y '- Gn� � --- .- ._. . . . . .. .
� p r�on Laws `_ ao�aeu.P..O.BOX -3329 .... - .- --- � , o
�. ,; ,:, :�
^� . . . ,. .,, . . .� . .,. . :... uTv Covina ziv 91722 ._I i oiT Ns. j - _.. _ . U
io
t fe APP������ � ARCHITER O � TEI. DISTRICT GROUV TYPE i � FIRE PROCESSED BY �
� JTICE TO ADPUCANT�If atra�maktng'this Certlficate of �� �ave Szan .AIA No445-4073��� o
ENGiNEER
, Exemptlon;'yoo'ihould become sub�ect�lo•the�Workers' �� � � CONST.� - �ZONE' . ; U
Compensallon provisions of the Labor Code,yov musf forth - � ADDRESS 314 N. First, Arcadia STA¶-,�.� .!. � {,tl
wlih tomply with"�.auch provislons or.�this permN shall be �-�-�--- _ . . � , ' �' " � ��'� . p,'
daemedrevoked., CorrrRncroA5H1UOVeEN ROU ��SZOS6O ��R�PIF�GT�oN � APT. �O. (n
ctass
; , . �. . � ,., ,,.., FNo. . _ : z
LICENSED CONTRACTORS DECLARATION�:�, . �. --��- � - -- - - ���, MSS NO.'�-°Z'�� 'OWEIL.UNITS��
I hereby affirm Ihat I am Iitansed under provistona of Chapfer 9 _ ADORE55 NO. �' �
(tommeneing wiih Section 7000)of Drvislon 3 of the Businav and .:... .. . ,.. _..._.., ....... � ... ..... ..._LIC _.. _ . � . .. , .
Proieesions Code,and my license is in.full force and effect _ ' c�TM 1314 j �5S . _. , � � � �� -�� � V��DATION �
.B. _ _ _ _ _ __ _ _
. ' ..... . �. SQ.FT. NO.OF NO.Of � CHECK BK. ', PG � ,,
License Number'51 O$6 O l�Closs B 5�2E STORIES FAMILIES 1 " ONE '
.� . .� �. .. . . .. YAWATION -
t THE ANDEN•-GROU •8/5/87, - oeseaivrioNOFwoaK ' am' NEW a s 6,820j• � �079,4A
- Ontro[lor afe ADD � �
Gara e.....44H -SF- n�na
I am exampt under Sea � ' �. --:.�..... ...... � .....� I .... #�a :•�r� �
_ ; , SLAS ONLY ' �, ,
��5� narure �his teason �..__._ � � REPAIR , ...s .`.. �' I- j -- � � �'��•�.i(�$,O b '.
. ._9_ .. ._ .. . _ _ ._ _ _,.��.� USEOF ' � 1 � I
oa��: -- exisnr�eioc. � I:: ._ . . :5&0 D�.,
8.8P C forot _ ._ _ _ ,- . ; •
" . APPLICAM� TEL ���
aawT THE AND N R
1.� WNER-BUILDER DECLARATION � ' � ' --DATE`..S .�I �._O�„ . .. _ �O S� 7..8�I �
-. .__. .. _..._._ _� - .. ._ . ... , �-
. �� ereby affirm that I am exempt from tha Controctor's Limnse �� -� AS above' �� _ � i � � -�� .
�w far the follawing reason(Section 7031.5,Basiness and � ADOaE55 �� ' FINAL'.�'' � �'.. ,� ��� . �
�fessions Cade): . . . . .. .__, . .. ... g N � Ey .- -a2«f� �,_
� � BNLDING � .
� �I, as owner of fha property or my employees with nDDRE55 ' � ' ' � i -
: -wages as their sole campensatlon,will do Ihe wark ond . .. _ . . . . .. � -- � '�� �•�� '-. . ... - -
'' the structure is not Intended or offerod for sale(Sechon ����TY � � '' ' ,- I�. . : � ,
��f- �7044;Business and Professlons Code). --� - � � ---- � MOVING-" ' � -�-�� ` ' tEL:� 1 -� �� - . � - - - �� -- �- -� �
�j .t,as owner of ihe praperty,Om BxCluSively ContfOCting COMRACTOR NO. � ` . . �. '. . .
�.•
i 'with licensed contractors to constroct the project�Sec �` REouiREo. .� . �. ..-- �..tOin .._�.. , .. .�.-�- --.. � . ' i �� I . . . ... .
.._._. .,.. . _ �
�. tion 7044,Business and Professions Code), nDoaE55 ' I ,. I ., � . . ,
"�- -'���-�" CONSTRUCfION LENDING AGENCY' �-'�' ' '�- ' YnRo- Nwv �sETBnCK �� i _ �`�,�, . . . � ._,
� SET BACK � �� PROG.UNE � ' WIOTII � �, � ! ,
1 here6y aTfi�m that there is a canstroction lending agency for ikONT � � � - � � �
I �.
- �Fie performance of�he work for wbich fhis permi�Is issued -. --. -v.�. - ... , .. _ . . _. .. _ .._ _. t ..�. : .--.'_ �. _ -Xi .. ... . '�_. .... ... . ..'
(Sec.9097,Civ.C.). SIDE , . . - ,
,} _..._ . . , �.. . ... � � i -' , . i I .. .
Lender's Nome-t.'1t1b3ri�C . � �P.l. . ... . . . . .. -. � ... - . . . .. . . . . .
� P'G Fee S Permit Fee ��S�I. ��Ref.N � ' - '
� �ender•sAddreas444 S. Flower. L:A': 90071 ' 50 � i -
� 10.50 ' � I �. _._ _
� ,..
-.I certity.that I hava read�his applicotian and state that tha _....,.�... . .._ , iuuan<e Fee . � .--.. :.� �DMA v/C�1 I._ ' .. _ . _�.
9 above Informotio is corcect.I agree lo comply with all County invesnpouon Fee� . i . �
$ ...ord�nances on a�e laws relating lo bullding tonstrucllon. ' _ Ta�ol Fee- .6�8•�� . `IDMq Perm.M�I -��' - ' � . . .
. ._ � .. .. .-_._. . .. . .,.._.. � .. .. ....... . :.
£ and here6y orize represanlatives of�his Covnry to entar�� , .
� pon the • Ioned property for inspection ppurposas. . � � � � ��
� . _. _ . ._.___ ..5/'�//,(/)� . ; _. . . . . ... . . ' . _ � _..._ .. .. . .._ . . .. , �
m U'� _^y/�.ry � .. SEE REVERSE FOR E%�UNATORY LANGUAGE � � . I . .
i -'
�' . ' StgnaNre o APClimnt or Agenf- ...._ _"-- ��— � _. _.. . _ _._ .. . . .. ... ..... .. . . :. .... . . _.:._ � � ... .. � . . _. .
Do e I
i ' . i . . ' I. .
�,, OR:N H I LI11.U7 H I71(1 AFt"''�1(�\
PlANS TO APPIICANT �INSPECiOR S NOTES N� 7��� �,o 0 0,s
{ f{� I h ehy of oi Yan c e t rro I�e
: ��I To: E.. �:�{Y,t�'i r.:. :..,{ �teluined i.1'.:'q y f.,.� ,r ��. ::a �s+�ry �. p� .F ��j� �y Z �l.�NC'.�. i�rLFce te la�n�Olo�tl� iol(�iwa j��t n c ��S, .Y��031'�55
. _ ... � .r ,.�E: E ��'�q� k.a�.. Y. C .,�nn n �
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,.� APProvod `� f , l\� !)��sine�crt.rJJ'sufg�innct,id iFlntertl,�i�� �niiull �.t .
� '� No. Date No:':•U::Da#c"•:`^��: r'.:'.1-+i}�iii���=:0 Y�d�L1G7 �' - rryurrcc u p<�rn�i�1..cn.nrri ��ult��nn) i r�!� l...k:r
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- -- - . -. _. . . - ,...tbut l r��s lieeq d/�e�r{ua it t f/,n•�r.y�s ;�f tl. G%i
.. ��. LaJf�� f?9� I.•�C",S .:.p.�. "trurtnr'sl.iren.i l..ur/Ci,Jn«.»(,,,�,�� nu q�u�t[ {iq�
— ' �:�-� �iun?Of)OJ o/Diriciun 3 nI Ihr llusin��xe¢nd!'n./rssi��nc
; � __.... � '^ �.-...% � �- ` c `��
; 7�,�. bncr:�;r_�1,-,. .�. _ ��CI.:_;n 7rII f�no��-.iQ„�,; JCiS'c;�e,/...itwii��.�,i.i��,pari�o��/..�,,,v.;Jit,�F�,��< ,,.rt��
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2�ti: -t•.c. i. ,.�_�c� » x.� �i.,�- �r-.U� b ��n , iU. .rg ��t�
� _Ro9uiiud ''`-_flafa�Rc�elyed --------T---- . am upp!�antJ rup r�n1 aub/ecfs,tli Rpp( nt�� '�i!
i (I'' APV ovols , or A rov d" � � . • encpenultV n(nnt annrr:lhan� L endr J J fl rs/SSl10l./..
' L-�-___ _ ' '°�" __ 3,Yas _-NO -'___PP "'� u.i'��1 ..__� vc�_ai�i.inat> . . .
, . _.._ .._ _ � . _ ... _. � �:• ��..�:�� �___._._��
�:� L I,as owner o{�he p operly".�orr.i,r.mpioy�r,e3��wi11.
lo�er Crrl_limte 1'_�'C `.� 1,_. __'; � x j�. --s- �L.. �x 1...�..,,_-.��.,y;i''_.�''�_.• i.��wagew os;�he�so�e comPenso�on,w II do rhe work,and
- - .-�1 ` ' .- k; ahe snud � �'s po� �ended o.oi�eredl'�o 6le Sg���70aa�
� ,'"\ o^c S'_ti_nr* n cr v ,,n. P�F. `, , t� �._ i��
HealthDepartment 2N r, ;I � J? r� ,.NUi sn is nnd.Pr�ess ri('Jr 1(e(, n!a t ra 1.�rc�se
� �' :$C�P- Ef ,l n )` . �� I. uJ�ean�t�pphr�¢n umer fprp tti�� hui(da
ae-De � or i rv s t! rc and u b t! e s h u k hi rs I/
partment;._— �.-� � —� � �
��• i •,�u� . 1 ��I r.»T �. �� �� � . ���, r �r ;�.�,' �_�C.�G� +? ).�(Irr�uFb�Lis.{nua�er f�G�r� pruivdi�(ut su7f-�:.
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I {_` Grodng � y, ..,, 'z:ofrvlt•rmCn�s a.n,�int in! IOfJPlI F�JAIICYPJJ�r�JP1�„lfi�.
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:� i,.; Geolo9icolJ J;A�'7 -� �L n,�:2'i.:�Y.�[.:.�a r.`, � .�.. - - '.- '.� � _ c:l {�eu�A/r2nm/�lefinn..tbe'auaer.huildervari!!,/ai�rithe .
� � I O'°'UC?;�'7 I_:�Cf��i/'_`t i ,�p i .i� burJrn�Jprr i n,�t/ f[e d d n,1 h !d rrrrprn rv�/rr
� �- i _ < .n ..� - -' �- � ' - �hr purp sr n(vdf 7� Z.�� . �. � ] J
Pedestriaq'.Protetnon i . . < � l'd C U 1 C�_ E�:'OC.1� ..(. .� .H: F "i J� .. �. . � �+� �
� (Fence,)�Co�opy� u^ 54t Ho��._ , --^---••----^ �-.r. t '; r � 6so �e of}F}epoperly ome c1ui�Jpfy��onliae��
�. Imy w�{,�2ensed to fJado s lo<on t "cr t}�e p ojeU($et
, . . . . . i � iea.t: Yi�Y� 1 'Gs � t �. 1 � �
,�, 70aa'Ur s e uni!1 lc >�(n.l II ( n,1 o r
� Specia�lnspechop� i ~'f-- --'� � "�T_-- - ��'� ` "`�� ' .,
� . . � f� r � /:tten l.ai•d r n>��pplt fo an J�u�q r r ro ertt u Irn
�Conr.}.(Mos`Bniy)��(Welding) q��. ' . ....... -.c._ ..�_._�._11..___=�.r..3._____�.._ .��'.�� �
�,I ' • NOt 1 n1+.V � �.:J ''—" '!. �^- '-fiu�t nr irir�r r�s IL�re n o iJ�eY�a�����ntructs Jur�su.h
Lo10�raino e1,; :� �. (r , -�� �� •. �-.-y.� ."�1�._•.a__�� ,;�. /�f���[tt�e•R! a �infr5�tv(�I�I�iniS�d J[�r��in( ln fhr
i . � tr� _ _ _-Ci � O t i C^.+r� ^—"'�j.— _}„ '-C�ntraifA�s l.icrnir7.au) ...J . "•.�••,�
..... n r r "'-�
� Park < e m �, � . .. . . _ . .. 4�;..: - t n°I� �
^9 m -^�am exem t unde Sec � B&P.C.�o�ih�s
� . . E�- l - ,�,� XilTi:? ���2.f.: �_.� _ orn z�dt _1..i.C:G
u v„.. �. � p�. i _
�, _ , ` ,� _ . _ . =',ti137� �-� �? ^eason . _ _ _
�i .• . � C, - . . �� Dare Owner
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A rovals Da1e C Rector s SI nalure � ' �" '���C � � i:l. ��t� �.: � . ^ .�� ... '. . ..
___
PP ��>. �^_ _ 9 ., ,.�.,. �-^ft Lnc r..e-:�.,!� _iEOC,INSPECTOR'SNOTES�,,I�.. :�+: �
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Locar�on- I. _ '..J`Y i-��_a�..., � .
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C/� a bnll N ' 1. t' - y � � 1 S
Foundations �
/ _.J vii '`�l nobeC). e.'a?b .rn.b.��r. L�nc.i ..U:�tz�n .
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