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HomeMy WebLinkAbout1572A 1573A WORKERS'COMPENSATION DECLARATION . ' - � �. . : � � I Fierehy affirm tha� I have a cerrifico�e o,�o�,e�<<o:e�t - � � - APPLICATION -�OR BUILDING PERMIT insure,or a cenificare of Workers'Compensalion Insurance, , , . or a tertified copy thereof(Sec.3B00,Lob.C.) � � � -' Pol+c No.�3wc005-2��m��6 NATI�NWIDE 36 C COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Y Ce�titied capy is bereby f�mished. FOR APPUCANT TO FILL IN nooeess 23626 E. Goldrush Drive �' Certified capy is filed with the coumy buildfng inspeo BWIDMG � ' fion deparlmenl. ADDRESS 23626 E. Goldrush Drive � Dare6-30-87 qPP���o��THE ANDEN GROUP c�Tv DIAMOND BAR ziv �ocn�rcr CERTIFICATE OF EXEMPTtON FROM WORKERS' NO.OF B�OGS. , NEAREST COMPENSATION INSURANCE - SiZE OF l07 NOW ON t07 CRO55 5 fThis secrion need nat be completed if�he permit is for one �SSESSOR , hundred dallars(S100f or less.) TRncr 43435 BLOCK LOT NO. MAp BOOK PAGE PARCEL TEL. U ZONE �P '7.-� S 1 cerNFy�ha�in ihe performance of the work for which this � OwNedCHE ANDEN GROUP No.967— �v/ r,�p. permit is issved,I shall no1 employ any person in any menner ADDRESSP.fl. BOR 3329 . saecwi . � so os to become su6jecl to Ihe Workeri Compensaiion Laws. - O C7 CONDITIONS � ' nTr COVINA z�v U �ole Applicant ' Lr ARCHITECT OR iEL. DISTRICT GROUP TyPE FIRE PROCESSED BY �'"'OTICE TO APPLIGANT: If, aNar moking�this Certificme of � ENGMEER DAVE SZANY AIA r,o.445-4073 � � cnNs - z �-�- emp�ian, yau shauld 6acome aubjecl �o the Workan' ,[7 U Compensation pravisions of tha labor Code,you must forih- qo0Re5S �d �'`'� j W wi�h comply wi�h such provisions or this permi�5110II be . . iEL. ' STATISTICAL CL45SIFIC(QION APT. CONDO. � deamad ra�okad. . coNrancro�'HE ANDEN GROUP No. LICENSED CONTRACTORS DECLARATION . �i�. QA55 NO. � DWELI.UNI15�/ z I he�eby aHirm Ihat I am licensed under provisions of Chapfer 9 ADDRESSAS ABOVE NO. 1 gy,�R MAP (commencing with Section 7000)af Division 3 of Ihe Busineu and , ���, � , Professfons Code,and my license fs in full force and effect CRY � C1n55 BK � � . VAUDATION �510560 B sae�1658 s"Toa°s2 F°ii°is i �oN� Licenee Numbe Lic.Closs � VALUATION �o���a��o�,THE ANDEN GROUP pOfe ' 6-30-87 DEXRIFTIONOFWORK NEW � s 1�0�000 :41 S7.2A ❑�om exempr�nder Sec. GARAGE 456 SF aoo ❑ � �� �� �2 � ALTER B.BP.C.for}his reason ' REPAIR s � � •3� �1 8�1� USE OF Date: - EXISTING BLDG. � DEMOL O R•1 � �H'T Signatura � APPIICAM TEL. . FINAI OWNER•BUIIDER DECIARATION VRINT THE N�� DATE (�/I�"/�Y . . I hereby otfirm thm I am eaempt 6om Ihe Contractor i Ucense qppReSS F�S ABOVE FINAL - law for the follo,ing reason(Section 7031.5,B�sinesa and �f�n� ��� 5 7�p Profesalons Coda: sY � I, as owner of}he properry, or my employeas with � AD�DRE55 . �• . • • • 1 wages as Iheir sole compensotion,will do�he work and ' � . Ihe struct�re fs nat infended or offerad for sole(Section ��u`��TY ' � ( •�Jr Q 7•Q Q 7044,B�sinesa and Profeseions Coda). - - - � rnOviNG � ?�" � �• �'�Et:' � '` � � I,as awner of Ihe property,om exdusively con�ratling COMRACTOH � NO. • e�S�•l•d�� , with licemed wnvacton to construct the project(Set- pppaE55 � � tian 7044,Business and Pmfessions CodeJ. ..!'' <'1 D 9,1 1 �8 7 EQUIRfD TOTAlSETBA K � • CONSTRUCTION IENDING AGENCY �Ser encK YARD� HWY pROP.UNE wioiH - - - " ,�. r ' � � I hereby aff�rm�hat there is a consrruction landing agency for feONi •�._�� Iba pertormonte of Ihe work for which lhis permit is issued � P.t. �ii��� �' " ' • - (Set.3097,Civ.C.J. S�oE ; � �r� ., �, - CITIBANK r.� � ', `� -; -• lender's Nama ' '��' �.t i p . IDMA Raf.N � tender's Address�+44 5. FLOWER� LA 90071 v.c.�es S 316.S4 Permir Fee �96.50 �� . ; � 10.50 I certify Ihot I hava reod this applimtion and state Ihat ihe . iswance F�s �DM4 P/C N � - - - � above information correct.1 agree fo camply wifh oll County Invesfipaiion Fee c�0'l.QQ ' ordinances an t e laws reloting to building can5lruction, To�ol Fee IDMA Fe.m.M� and hereby rize represenlativez of this CauMy to en�er - - upon 1 e ' ned propeny for inspedioryqu oses. � 5� LDMA $75 $35 !//4 SEE REVERSE FOR E7f►LANAiORY LANGUAGE�� Signo�uro oi Applimnl o•Agenr � po�e . . � , ; INSPECTOR'S NOTES ...Qlt'NIfK-IlUll.l)P:H!)T:CI.�\RA'7lOV PLANS TO APPLICANT I hr..e6y o�h.m�fF�oi 1 arn e.empi�4rom�ihe Con�rar!o'�s . .�� � . .- � . � '.' , . � Lic ��e Ln f. tfc.�follown9,r�h�on (Sec.' 703� 5; I To: � � .. , Retumed „ -. ,:• - . . . .. , . , . ' �APProved� /3risunr c�rsd!n h.�<runt Cndi:An�zi�> >r:mrnh�vhi:b . No. Om¢ No'. �, `Oa1e: . � -.-.. . � . . '' � . . � rcyuires��•<�rn�it.fn tnrt�ln�rl.a!lrr..imj�rurr.drmnlish, _�.,� ---.- . . .. .-- rr/vir unti.v'irudvrc.Pri rtnitxi.�.cu.+nci�.J(.nrvquirr� � , - , '�I'�, . ' Ihr u/iJ�/i:Jrtt/i.r tulh(�rr uif f�i�i(r'a.Si,Crtrtl3t.�lrmi•rsl � � � , . ,. . ; � .. .. -,. _ . . _� C:,� :, ,:-�: .� .: �.� �,._ .. �� � � --� ' � - _ ._. . . . � •. . _._'__._... .. , _. _._..- _. - -____ .. .tba!be is Gienxrd/ruecu.�nt�u 1L.<•prurieions u/!Fr<;.ne- ':Q ;'7•' .,i' �� '��:�`� ' . trrtRor'sl.ie��nsul.ai��(C/.a/��rr)1(av�uin�c•n�in.C�riN�.lcc• ' � .. ri . _, .-. . .� �. . . __ .._ '_._.._ _.. __. __. ..__... _. _.. . ._.._._. . . -. .'__ _� ._ ...._ '____._ " - tiun iU0f1/uf,Uiri.i��n 3 nllbr livsince<�nd PrnJv.�n�nc . � �; �..,� �: ,. � -.- ,.,.- t:"--.-- ,- •": �... ' .- ---...-- -.'CoJe1'nr ibat Le ic e.rrnep7 tl arr/r,vn�nJ thr ha�i.J„r tl,e ,".'� ' __'___._._. ______ .. . „__.., . __.__ _ _____ � . . . - �71r,trJ erenifNan.Anv rinlation r�Se�tinre 7U3 L9 b�. �. ., ..,� , . ..�� - .Roquired - 1 ::� . . . .. , ._._.__._ _ � _._.. . .. . _ ._._. ._. . _. an�•appli.�nf/uruprrndt�ubje:estbeafpluan(lna:i�d ,, .. ' -_.._. _� . .._._.. .! Dale Recetvod �. � . �' . . ' AAProrals or Approved,.,. ' ,.. prn�ltl nI nnt mnrr fhan,/ c L Jrrd Jn!!an(5$OUI.p ; - . _.._ '��Vos ,No_. _ . _'_'.__.:-'�__ �� _... _.____::. , ....'_�'.. :._, � , ' .. . , __ I,os owne�of the p op.ny;o�my employces wit� 1b'g!e�_Ceri���co�e _ � '�� � ��' • .. . �" -�- . .' .. _..--__ -- � _ _ . . .._ ._ . __ „ wag:s as ihe�,sole compensn��on,w�I do�he H�or .on� I F �-- --- - - - � - 7 �`/ . Ihe s r.ucW�e is na iMended p�ofle�ed fo�sa��(Se:70a4) Nea��h DePo�tmeni---�-- ''"' �I �.i` ,�. �.. __.____._ _.__.. —._ .� _..._... .... . .. . ..:��usinesvund Prn/rsrinn>CnJe:7'/rc Cnrrtraatnr'.l.iccnsv _' " .' __._ . . _ - -. . , � l.au�d,���,��,��r�r,•,,,,,,�nu nrr u/prnferh ia L���Fui(J� r. . . F,.e oe„�.�mP„r — - —- – _ ��.�„�p., �,� ., �, / � tho ��m.�nJ m n duc�nn!u.irb!•rmul ur , - . ' . , .•��fb ,�b'Li: n�on -emplo}�res. prur,dcJ�efiat xur{� iw-� ' �',rndng . .:,- + � ��. . , ' ``- � �.�./rrnt•rrnrntr are not infrnJrd�ur n��flC(��U! mA�. �. � ,. �. ,, ., .. ' , 'i` 1' � �t. � . . .,. l�.. ., ' ��'�.bn�re�er.t/r 6��i1JinR ur inrprnerurnrn�ia snLf u rtl in nnc --- �-,-- : � - - -- .. -� . . . ' . '...- ` � . ... - ' yeur n/com/drtinr. 7Rc ��v•nrr•FeulJ�r u•il!1��re't/�r . . (;eo!og�cof- . ' .. . . . . . _ . ' , ' ' � , _' ._ _._ .. :,_' _ :'._.: � .;�._�' .. ..: ._.''.�.; burdrn o/frne in,t'!Im!!,e JrJ no!Fui11 ar'impror r fnr . _ . . . rhr.pu�o�e of 3�r<�r:'�� � . � • � . , . .� _ .--. . .. ., Pedestrion Protection.. "� � �.". . �� ", , „ ' :.. �. . :'. ' � � - .d�s��+elycent•nc- (fence)�Conopy) � • � , -.�. . . . ' - -�--`�-`�- � - "...- , � J ,I.asowneroithnproperty,ame . ,, . � ,�ing wnh Lcensed cpatracto�s ta cons�ruct Ihe pw�ea�Sec . . , .,_ ._ _ _ .._ _ .._. ... . . .._'.... . . Speu I I sp_Uion -�-' �-� "' .., � �.� � , . 7044)Uusineac Jnd lr/•�sinn�f.oJ�^7�Gc(�orttru�tor's (Ccnc 1(h,osonrY)(Weldingl � . . . . • , -- ' -- ' ..- -.__ . _ _ ._._ __ l,ircncr l..�m J s n t.epf�y 10 ui�nu rs��r rf prnprrt�d�hn '. , . � � �- burJds or iin/�r ca fI ern �n!ml�. < fru�trJn xu�b LoiDrolnahe .', ('U�_.;i.� �w ' . � . ..._._._.."' -..._ _ �..�_.. . _... ._._.__.... , - �jr��t� u�iti a. r�tlll!i . Jprr . . . ! I �rns� zuanf tn t1�� �._ , nntro�luri l.arrtSr f.au•). � - � , _. . i . .. .. ._ . . � � . . . . ., . � � , I; . . .. . , � _..__' '._ _-_ _._.. __. �: _ . . _a Porking . . � : '.':. .. - ___❑ i am c.empi undcn Sec .8 BP.C.fo•th�s , ' . -_-___._.____ .. . . . ffU50n �, , .,: . _ _."..".' . _""_ _ _ .. _..__. ....._ .. . _ . �. _ . ._. _.. ._ -._�...._ "_ '"' '__._"�"""'__'" '_ _'""'_'"- __" " ' � , Dale �w, . . . . .______.—."__'__._-_.. -.., �.�... .. .... . . , Approvals Dotc � Infpectoh Stgnature � , . � - � � . � .. :. . . � .. INSPECTOR'S NOTES' �"� � , lom��o _.-'_ ._ ___-.__. ___. . � --� lSethod.&Yards) ' '� ' �' .... � ' '_- - -_. _. " -- ---- - .. Foundar�ons . .:.. . � .,.. � �. � � . . , . � . � - _f� a __ St�b , . .-- -... _.. . ___.�- ._ ._ ' -' .. - . . .. ,. , ., � . F�aR,e ' ���� . . �. . .. . ,f . , . . . . � . , .� ' - � Energy Insula!�on -_.�-_- '_____. __ . __'.._' _._.._. __._._ .._ '_ ' ,.,,,., .,_ . , ' _ -. . . �. Z` ,a . ' + , . i. T _- — a l��h;Drywoll-- , ___ -.._.—'__ __'...'_.'.' _.. -_'__ i_.__ _ __,. . . ' . _._'_ _ _ ___..._._ . I ' ..,' ... . , interior ���� i � . Lath- E.�erlor O •— , .. . . . . .. .. . . -. . '__... _.__... ..__.__ .'__- . _ _. . . .� .. �" r -- . . - ----- - - ------ --- -----_�_:. _ --- - Hoose Nomher- , �. - "� � � Correct 8 Posied `•". 1 • ..i,,. . ..„ ,_ . . . , _.._.. ______ . ___'-_ __-- '__ ._ ._. __ . ...., Fmol. � . _ . , � . .. ' . _ . , .. . . . �� . . � Enre.on Frani '� "- - - � - �, .. . ' ._.. . ... . . � . ., � _, .:�: .. � � ��. � \\`_ _ .. . .. . ' - _ ,_ . .. . ;a.���� ct�':\,. ��,._1! , . ,. ..,. _ . ,�',� . . . . �.� ' ._....�.� ._.... _'._._ _._____'._�_..__ ...._"___ .