HomeMy WebLinkAbout1516A 1517A (8)WORKERS' COMPENSATION DECLARATION APPLICATION -
insureby affirm that I have r certificate of consent to raself - FOR BUILDING PERMIT - -- �]
insure, or a certificate of Workers' Compensation Insurance,
ora certified copy thereof (Sec. 316 Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.73WC���m��,6 NATIONWIDE
E3 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN FOR
ADORE55 23606 F.- rn1,1 • .h Trim
Certified copy is filed With the county building Inspec-
tion deportment
BUILDING
ADDRESS 23606 E. Goldrush Drive
Doie6-30-87 Applicant THE ANDEN GROUP
CITY DIAMOND BAR ZI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
TRACT 43435 BLOCK
LOT NO.
(This section need not be completed if the permit is for one
hundred dollars ($100) or less.)
OWNEFTHE ANDEN GROUP -
TEL.
No. 6
1 certify that in the performance of the work for which this
permit is issued, I shat( not employ any person in any manner
sees to become subject to the Workers' Compensation Laws.
ADDRESSP. O. BOX 332
CITY COVINA ZIP
91722
Date Applicant
'JOTICE TO APPLICANT: If, after making this Certificate of
�
Exemption, you should become subject to the Workers'
Compensation provisions of the labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
ARCHITECT OR
ENGINEER DAVE SZANY AIA
iEL.
NQ.445
ADDRESS
0
CONTRAmITHE ANDEN GROUP
TEL
ADDRESSAS ABOVE
,LIC.
NO.
CITY - -
tic.
CLASS
SIZE�2774 S1oR�s 2 FAAv�Es
1
10560 B
License Numbe tic. Class
DESCRIPTION OF WORK
STATISTICAL CLASSIFICATION
ControctorTHE ANDEN GROUP Data _6-30-87
GARAGE 643 SF
ll.
ElI am exempt under Sec.
CLASS NO. � DWELL.
UNITS
B.BP.C. for this reason
Date-
USE OF
EXISTING BLDG.
SEWER MAP, '
Signature
OWNER -BUILDER DECLARATION
APPLICANT
PRINT
TEL.
NO.
gDDRESS A$ ABO
BK. PG.
-1 hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
^Professions Code): - - - - -
_J I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not Intended or offered for sole (Section
BUILDING
ADDRESS
ONE
LOCALITY -
MOVING- -
CONTRACTOR
TEL. '
NO.
7044, Business and Professions Code). - -
❑ I, as owner of the property, am exclusively contracting
- with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
ADDRESS
REQUIRED TOTAL SETBACK
SET BACK YARD HWY PROP. LINE
CONSTRUCTION LENDING AGENCY - -
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
FRONT
P. L.
S 164,000
SIDE
CITIBANK
Lender's Name
P. L.
P.C. Fees 431.08 Perme Fee
685.
Lender's Address 444 S. FLOWER. LA 90071 -
luuonce Fee
10.
certify that I .have read this application and state that the
Save Informati correct. I agree to comply with all County
-dinances a _.7.. laws relating t0 building construction,
J hereb ize representatives of this County to enter
m f y for inspect gggdr1pase:.
Investigation Fee
Total Fee 696.0
LDMA $75 - $35
DEMOL ❑
SEE REVERSE FOR EXPLANATORY LANGUAGE
• Signature of Applicant or Agent - Dote
—4073
SO
SO
MA15-66M
PAGE
PARCEL
_
US(5�/ ONE OP /17-3
/O SPECIAL
JO 600 CONDITIONS
— 2
•L,
U
0
DISTRICT
GROUP
ttPE
CONST
�
FIRE
�70g7E
c1
PROCESSED BY
�
U
STATISTICAL CLASSIFICATION
APT. ONDO.
ll.
-.
CLASS NO. � DWELL.
UNITS
Z
SEWER MAP, '
CHECK
BK. PG.
VALIDATION
ONE
NEW ®
VALUATION
ADD ❑
S 164,000
ALTER ❑
,
-� 1 5 1.6 A
REPAIR ❑
$
-
} • • -21
DEMOL ❑
I -431.08
FINAL
��
DATE J -
_ -
e e 431.085
FINAL
By
0 9. 1 1 —87
/
151.7A
WIDTH
(•5900
••696001
i
09.1 1 —87
LDMA Ref. It -:
P.
P/C R
0
LDMA Perm. R
-OWNER -BUILDER IDL UARAHON
I hereby affirm Ilial I n exempt from the Conno-toe's
Li<r. ase La for the follavr eriy, reaton' (Sec. 7091.5)
• llusincss and l'rulesrinxs Code: Any city or e.runfy uhirh
rryairrs u prrnrit L, qnl srnrrt, altrr,.irxprnrr, drrnnlith,
----nr repair un y siru rtu ir; prier P, it} 1*1c'anai-,-al", rryrnir,
Ibe applicant for such pi -nit to Jile. a signed staterrrenf
that he is./iren.wJ pursuant to the provisions nl the (:nn
frac toe's License Lau• (Chapter 9)(.'grnrrrgncigp with Ac
Nun 7000) r,Mvi,iox 3 nl for lfasixrs, and Pmf, ,mn,
Ga/r) or -11-1 ti• is e.rr nrpt the"Inndtf," si, fur Ib,
,Urged exrnepti, n Any vialatian r/dvstiuu 7031.5 Gr
auy applicant/,"', prrnrit Subjects Ibe upplimnt h, a e ird
- penalty ,f nat arnre'that. /ire hundred Jollnn (550(11.1
os owner of the properiy. or' my employees wi6,
woges os.theb sole campensouon, w 11,cle the wars. and
the structure is eat imcnded or offered for We (Scc, 7044)
. Business read Trn/essiaas,Cod,: 77,e Can trariurS hicenfe
Law dnes of apply ter an au r o/property n•h., huilds
or irnprares thercnn, _— d sJ rr does fu, 1> u•orl: hinrsel(or
tl,-.gb bis osn, en,plgyres. prrridcrl.. !hoot ;suet: it
-- prof•ements are not intended for atfvred /or sale. -1l,
' .bnu-ever, rhebteilding nrirnprorenientissold within one
yea% (o% rnnrpletian, the nsnner;builder it -ill have the
burden rr/ pr ,hjgq rl nt 1,e did not build or ietf--e /nr
the purpose of rale).- - - -
!._� 11, ds owner of the p.operty,'am c.daswely cnnt�ac�
-.ling with licensed contractors to coniauet the. project (Sec.
7044) B-ines, —d 1'rn/rvinnf CuJe: the• Cnntru<tnri
_ License Law does not apply In an nunei;i,Jprxperg v -hr,
builds or improves for eux,-and iib,i-3„nlra,f, Jur- such
pro jecty ,u•ith a cnntrucq>r(sJ U --ca" pennant I,, the
7.
---'Crrxtraehrrk f.imnsrare')•_ -
-_
I am exempt
__- .. ._ t.•
t under Sec. 8 BP. C. for this
reason
Date 0. net
INSPECTOR'S NOTES"