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HomeMy WebLinkAbout1556A 1557A (9) WORKERS'COMPENSATION DECLARATION �.- .. � �� � insure6or�afcertifca1leafWokers''Compensa;o���;��a�e` �� APPLICATION �FOR� BUILDING �PERMIT , or a certified copy ihereof(Sec.3800,lab.C.) COUNTY OF LO$ANGELES BUILDING AND SAFETY roucYNo.�3wc005-2�7��(��6 NATIONWIDE 61 B 3 Car � Cenified copy�s hereby furnrshed. FOR APPLICANT TO FILL IN ADDRE55 23612 E. Goldrush Drive � Cer�iiied copy is filed with the county building inspeo- � BUILDiNG tiondepartmenl.� ADORE55 23612 E. Goldrush Drive Dote 6-30-87 qpplicont THE ANDEN GROUP c�n' DIAMOND BAR z�v9ll65 � �ocnuTr DIAMOND BAR . CERTIFICATE OF EXEMPTION FROM WORKERS'- � � -- � NO.OF BtDGi . . NEAREST � - � COMPENSATION INSURANCE SIZE OF lOT NOW ON l07 CRQSS STDIAMOND BAR BLVD. + LDE , (Tbis section need not be completad if the permil is for one - � TpqR 43435 BIOCK LOT NO.42 MAP�BpO1C � PAGE PARCEI hundred dollars(5100)or less.) . . TEL I certify ihot in ihe performance of 1he work for whith�his � �" OwtaERTHE ANDEN GROUP No.967-9541 USE,2QN� �P �✓J 3 . permir is Issued,I shall not employ any person I�any manner qoDREuP.O. BOX 3329 � �C CON�7ION5 0 so as to become subjeU to the Workeri Compensation laws. /����, ci�r COVINA ziv 91722 v Date ApplicoM ARCHITECT OR TEL. - a /'�VOTICE TO APPLICANT:�If, atfer making�ihis Cerlifi[a�e of ENGiNEER DAVE SZANY AIA No.445-4073 DISTRIC7 GROUP T�YpPyE5� FIRE PROCESSEDBY � t xemP�ion, you should�become wbjeU to�the Workcrs' / ` 3 �q/'� U Compensarion pravisions of iha La6or Code,yo�most(ortb- ADDRESS !V �' % � W wi�h tomply wilh such provisions or thi5 permit Shall be _. iEL. - - STATISTICAL C1A551FICATION APi. ONDO. z deemed revoked. tordrancrodTHE ANDEN GROUP No. LICENSED CONTRACTORS DECLARATION . . -. . �IIC. [LASS NO. � DWELL UMTS�_� I here6y affirm that I om licensed under provisions of Chap�er 9 � ADDRESSAS ABOVE No.510560 ��R�P (commencing with$eUion 7000)of Division 3 of the Business and , _ . . IIC. . Pro�ezsions Code,nnd my license is�in full force ond effett. CITY Ctn55 � BK � � � - VALIDATION �10560 B ¢e�'2634 50RIOES L AM°is -1 oNeK Litensa Numbe Lic.Class YAIUATION ' ContractorTAE ANDEN GROUP pa�e G-3O—S� DESCRIPTIONOFWORK ADp S 157�000 ❑I am exempt ondar Set. GARAGE 649 SF ARER , � � ��b A D s #. . . .2t B.BP.C.for lhis reason REPAIR �� � � � � - Date: � USE OF DEMOL ❑ � � •4 1 8.5 9 EXISTING BLDG. � Signature APP�patNiT THE ANDEN GROUP rio. FINAt • •�i 1 $5 9� OWNER-BUILDER�EQARATION �ATE ��/�� . - , I hereby affirm�hat I am exempt from the Commcror's ltcense qDoaE55 AS AsovE � � . . 0 9 1 1—8 7 Law for tha iollawing reason(Section 7091.5,Business and FINAL Professions CodeJ: . . . . . . . . . - � ; 6Y ����,,,,�t��s2 � BUILDING i - I, as awner of Ihe property, or my emplayee�with nooRE55 wagas os thair so�e compensation,will do tha work and ��i�n, . � ' . . the structure is not intended or oifered�or sale(Section , 7044,Bvsiness and Profassions Code). � MOwNG � , � "TEL. • � � � � - � I,os owner of Ihe property,am exclus�vety mntracting coNTaneroe No. � �� 5 5.�I A wifh litemed conlroctors to conslruct thc projetl(Sec- ADDRESS \��, �• • • • •� tion 7044,Business and Profess�ons Coda). .. _, REDUIRE� TOIALSEiBA K � ' �I.�11�' ! CONSTRUCTION LENDING AGENCY SEt BnCc YARD HWY - FROP.LINE WIDTH � - � �� I •(��J S.O O I hareby affirm Ihot Ihere is a construction lending ogency tor FRONT x�: r:'_�_: Iha performonce of Ihe work ior which Ibia permit is issued - � c.L - ' ` ' , �' ",i � •(�%5,��� (Sec.3097,Civ.C.). SiDE � ._'' CITIBANK '` . ' � 0 9.1 1 -8 7 Lender's Name - .... . IDMA Ref.M -t:. .-�,I,�. m lender'a Address 444 S. -FLOWER� �LA 90071 � P.e.Fe�s 418.59 v«mn Fe� � 664.50 _ , r . � ' ' � � � 10.50 1 certify that I have read Ihis opplicaiion and state that the . iuuonca Fee- mMn P/C M obove informati correcl.I agree lo comp ly wit h a l l County Invevigauon fee � . . � ordinances a S te laws relating to building construcfian, . iaol Fee (�] .��� IDMA Perm.Y - and hereb� u riza represen�ative:of this Caunly to anter � upon the m p�ny for inspecfiCo/n �Po�es. �� $�5 - - �� $35 � � (} ` SEE REVERSE FOR E](�IAHATORY UNGUAGE . �Signarure of APPlican�or Agan� � pore . . . . . . .. . . PlAl7S TO APPIICANT INSPECTOR'S NOTES . U�t'Nlf12.11L111.1)P:R UGCLARA'I'10\ . I hrrrby ofl rm ihnl I am r c epi f o Ih�Coro-ac�or's Tm E_ s ,. , �.. Relurned . �� ' . '.. i � � . . � .. License La.� fnr fhc'follnw ng r�a rn��(Se: -7091 5 .. APProved� � ..�.Bunrzrcc nnJ!r/ i r s(nJ AnYati ir ur�tP eeAi,!' No. Date No. ": Date '• ,. - � . , - �? �:i:". .. , . reyuir c u fe r��t r���nnctrurt.,altrr.(m/r�.r�•.Jrninli�L. ' ---- - - -- �r.�poii�n�� t ct ,.P r t i.�,,.�,�<r:Nl..nrryur .� ' i [;:. . r . _ . , .. . lfic u���fi:m�f/.,r e.h rrrmrt tn Jilr a ti,�nrd s�.+trnr��nl ,, � . �. ._ ... �. .'_ i �' '_ '_ '___ . �_' . -__..- .__. _' _' ' _, _'_ ' t � e � . .- .� ". .. . �tfiat/�r.is Gaens�-Jpursu�n ��t1,� prnrisi�,ns 1h� :..,� �/ f � . ._ : �, � .� c '_:• ��. tra.inr'cl.icrnrrl.u�<�(f,hJfl�r'JNu.u�nr.o�un�u�i�l�.ti�- .._ . .__. - ____ ._ . . ___ _ . . _ .. __ ___ . _... _ ._. ' � %.''' .' .', ' �' _.._ i.<,'•.�.�. _ .. s n , .. rrnn ?UOlIJ oI U�rpc„�n 3.�f dv!7u i ra,md P.��fr;r5r.ns . . . ..� ,' �,,' :e-- `=.CnduJnrtl.atL�eice.`e�m/rttlemfn,munJlbrhn.isf.,rfhe _ . ____- .__ _. . _- .. .. . .. - ___ _ . ._. � ... � !7 d �A '! ' ' ' . '.` ..� -.._ � .'."�- _ �Raqui�ad=. ��' Dat Roeenod '--- ' '-'�� .' -�-�" " "-� - '._......�_ .. . uni u�pfF un%nra pernrrt srihj���tr f r��q�pfic��n�,to a Se�rl �, Approvols or Approred � . ,. , � prn i9 nj nnt nrnrc lhan/u•c huadrrJ JnIIJn/SSb01.J. - '� '�Yas No ��-�� � ° . . .'.. ___ .__ . . . . .. .' _ _ _.._ . . . . _ .. ___-__ (-� � .. . . . . - .; �. , .,.. ., y • I as owner f rh pr pnr y, m . y r� n. Wo�e.�r.rDt�co:e . __ ��� "• •1 ' + .���. - -- ' -._ �.. .__ . _ ._ ".' . _' _ ,.,:woges Ps Ihe�r sole,compen�sni on.ovill de he�var'r,and _ � . ��..the siructu�c ii�ncr iqtended ar oife.ed.Fo�sole(Sec 7�4d) Heol�h Drpo•�mero—._-_ __ .. - .�.. . _:. ___�_..''�_.� ...___._ .__ ._'___ .._ . ..__"� _, . . _.�.�__.-_._..' .;..l3usiness an1 PniJeasinns C.ude:.7hc(:nntrarrnri l.i.�nsr � , � l.aao dnrs no�op/�lr�r�wn n mer oJrrn/�er14��•Ln Fuibt.� ;.-,,. ,,� ; ' i�"i.. ,., Fue:DepoNmenl _. _._ _ __.__... ._. ;. ... _ .•- . •.� ��rinefrnrrsth�vrnrs.unJu�l�nJoecsa�i�u�orkl�irnsc//nr l; ' ' . � :flrr���,�!}L�is h.rinplu�res:�prn� diJ lbut sucb rn.-� � Grnding ',- � � '.,I� � �� t: . _ . prnrrmcnfr a r�n t intradeN w //� •J/nr ,rrilcr�. . ••` , �:�. , , '''�. ' . , . . ., ,'- �._r:._.`.: . � bnrree�er;the bu�lJrnK rir rmp>r�nrnrrn!es sulJ uxtl in nnc , .... .,. __. _ - ____ ___. .... _. . . , :, G �9 - � � . � ' ' � o�mnrp/etu>rt, thr numei.AvilJrr a�i7J 1 nre the � eolo 'rcnl . . � ,-� �. „ � ii�. ' . �t�. i, ' „ Veur ' � ' _._ . .__. � .___ . ._ . ._. . . _ . burJen n�hrnrrn,�lbu�l�r diJ n��l hui1J or irnprnrr 7 r i Pedesvian P.otection �...'.. .�. . � . .. :�'..:. ', ; �.I�.,.. . _ b purpr�s��nJsale/.�� ' �? . • . .. t � Fence Cono � � � ---' ' :.. : . ._. .. ..� , . � . . � ( )( PYI , ..,. . . .- - :... .. - ..._..--. . - ' ��--�`�� , . ��,i:1,os owner of ihe propeny.am o.:l i�v�ely cennoc. .-.. , '___'�. .,. .linq wrth Gcensed contractor,to<onstrucl tf�e ro�eR(Sec. , . � _.. ._ .___ .. . .-� -.- ' - -.�-----.-.. - '''- . " 70a4 U��siness�snd Prn r.vinns�C.ide: 7be Cnn1r��Mr's Speual Inspeclio�� . '" - . -- --� ) /� � .. . . . . . . . ..' ', .�.�; .. �Gonc 1(h1asonrY)(Welding) ' •. .. . . . . . _ " .. _ �" Lrtencv I,utrJnrs nnf dJ+fl}fo.tn nviirr r+f proJ�ertv u•/rn , .. . _...._.. ." _� .. . _._ -.. __ . �' •.. � � `• . `:- , "-'huilds O�Iltl�Jf�PCf IIJPYCbR.Yd�I t1'I�.�nm�rucu Jur au�Jr : �. ... . .. � lot Drmnage , ' ',;;�,.:...'` ". ` . ,_.._.....:.. .......�. .�.� _.._...__ "'..._. prnjects u�i!!,n ��ntrucfnr(sJ li�en.erA prrrsu�enf tn the � � - -� . �. .._.. C�1M1�I�lCli)If�.tCPrl.iC�.!((f'�•. _ ... .... .. . . . . . .. ..... 1 Farking . . ' : ,. . . __..___ _._.. _....__._.."__.. . . .. ... .I' ,, � [) I om c:empl under Sec :B BP.C.�o�rh�s . . .____.__-__'__'_�__ '._.'.__ �. ,. ' ' � IJ . reason . _ ... .. . _..___ .. __ ._._ .._...___..__.._..._.__. __"_. "' "'_ "'___ " '_'""' '.. ...._.. "_' �, , , . . Daie O ner . , "'.._..__ ..._..._._. ._ . .. ',. � ,.,., . . . � . Approvals Dofa Inspedor's Sfgnofure , _ � � � ��� _.. � -,� . ,. .- � , �INSPECTOR'S NOTES� . � ' . . Loca��on- . _. . . .. � . ., ' -._._.._.. . _._.. ' . � i5erbock G Yards) . , - �S. ---- . --- . �' �.,: �� .,.. . . ' Fo�ndntions .. : , ��� / -��_ �' ` .. - � ." � . , Slob , . � .- � ✓f- -_. -- .-. .,: � . . . - , . , . �. � . ,� . . . - F,a�nF L��� �. " _ ,. . _. -. . _ . � � Energy Insulaa�on �. :..-_ ._.. ..' ' �' ' _.____ . _ :_ . ___ . _ .._ , .. � ,. . .. . ��_g� � ; , , , , � . , ..... _ , � � �, ,. ��+n;o�,,wan-- — -------- - , - — - -- s, � r --� — _ _ --. - -, �. ����„o� 1- , La�h-Ezeeror � I —� ' . . ` .'.. '. . . . . - . .._._ . . . a,.i. ., , -- -- - - - _��- � ---` . .-, _ , - _ _� . ,. Heuse N�mber_ • . ._ -.--. _ _'._.__._.. _'_ ___�: � , .. . ..__..__ . i � .. � . .�. , . . Correct 8 Pos�ed - � l __U� . __.__ '___ . .._.. ' '____. . . .. .. � , .. ,,., i. Fmnl .. . . - . - . � . r ' ' ".. ._. _. .. _ .__ _... _._ . __.. _.__._._'_' Ent=r on Front � � .-. • . , , ..,� .�c' . . ,.. . _ ' ,�i . .. . . .. . . . . .. . : ' . . . ' ',' . .. ��_� �``, ' . ... � . .. .... ._ . ' • _ - .,1tt�, . . . '--.. ';��`..�y�-r�=-,��'r•��� _ .