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HomeMy WebLinkAbout1554A 1555A APPLICATI WORKERS'COMPENSATION DECLARATION � : . � - �� � � I�hereby affirm thot I hove o cerlificote of ConseM lo se�f pIV �FOR�BUIL�DING PERMIT - insure,or o certificore of Workeri Compensotion Insvrance, , or o certified copy lhereof(Sec.3800,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � PolicyNo.�3wc005-2��m��b6 NATIONWIDE 61 A 3 Car � Cerrified copy is hereby(orni:hed. FOR APPLICANT TO FILL IN ADORess 23638 E. Goldrush Drive � �Cerrified copy fs�filed with the muMy build�ng inspeo- � BuuDING Z . �. lion deportmenf. ADDRESS 3638 E. Goldrush Drive . Dateb-30-87 APPi;�a„�THE ANDEN GROUP [itv DTAhIOND BAR ziP91765 ip��itv DIAMOND BAR ' CERTIFICATE OF EXEMPTION PROM WORKERS' � - - � NO.OF B�oGS. . � NFAREST � ` - COMPENSATION INSURANCE SIZE OF LOT Now oN ior caoss sTDIAMOND BAR BLVD. +-GOLDEN -SPRINGS . (This seUion need not be completed if Ihe parmit is for one rRAn 43435 BLOCK �� �� lOT NO.39 �E550R hondred dollon(SI00)or less.) _, , MAP BOOK �PAGE vARCEI owNer�'HE ANDEN GROUP TE`' us�oy� �P No967-95G1 J/�,� I tertify that�in ihe performante of the work for which Ihis �� / NO. � permif is issued,I sholl nof employ any person fn any mannar qppRESSP•O. BOX.3329 SPECIAL . . . so as to become subject fp the Workers'Compansotion laws. � IOODC7 CONDI710N5 0 ciTv COVINA ziP 91722 v Date Applimnt � LL' �NOTICE TO APPLICAM: If, afler'makin lhis Certifimre of ARCHIiECi OR , TE�. DIS7RICr GROUP ttPE fIRE 7ROCFSSEO BV O s EN�iNEER DAVE SZANY AIA No.445-4073 �a Z U cnemption, you should become subject to the Workers' �l �t�/ Compensation provisions of the Labor Code,you must forrh� qooaeSS 14 N /� V13 Jv � w � wiih comply wifh such provisions or �his permif shall be _ . . 0. deemed re�oked. - �.. � � �EL� � � S7ATi5TICal CLASSIFICATION APT. CONDO. tA coNranaor�HE ANDEN GROUP No. ,� z UCENSED CONTRACTORS DECIARATION , . _ _ . ii� cLa55 N0.� �� DwEIL UNRS� I hereby affirm�that I am licensed under provisions o{Chopter 9 AODRESSAS ABOVE � NO.S 1 OSGO (commencing with Section 7000)of Division 3 af�he Business and ��� ��R�P . Professions Code,and my license is in(ull(orca ond eHett. CITV � MSS � BK � VAIIDATION �1056� " B �, SQ.EFT.z634 S ORI�ES 2 F MIL�IES 1 CONEK - license Numbe lia Class � � VALUATION. . HE ANDEN GROUP 6-30-87 DESCRI7TIONOFWOFK SINGLE AMIL Cont.octarT Date N w S 157�OOD �I am exempt�nder Sat. . GAR�GE 649 SF A�� O ,� �.+� �J rJ.4 F1 ALTER 8.8P.C.(or fhis roason REPAIR � s '� n• • • ►'�� - oate: Ezisr�iNc a�oc. � oem�a �� .� I •4 1 �5 9 � SignOtUre � � APPLICANT' - TEI. . . . FINAL - OWNER-BUII�ER DECLARATION PRINT THE ANDEN GROUP ' No. DATE ��1"/y� • "t�� G S 9 v � I hereby atfirm ihof I om exempt from the Contractor's Ucensa Aooaess AS ABOVE � Law for the following reason(Section 703L5,6�siness ond FINAL - O 9,� � —8 7 Prafesslons Code): �� �� � �- � � � R N BY !�s'"� r""^ BUILDWG , ��� J I, as owner of the property, or my employee:with nookE55 woges as fheir sole compensation,will do the work and ' � -�- - � - � t �, � � � � the strutlura is not intended or offered for sale(Section �� lOCnIITV ' ' r 1 5 5 5 A 7044,Business ond Professions Code�. - MOVING -- �7EL � - � �� � � ❑ [ON7RACTOR NO. '�. �� • • 1,as owner of Iha property,om eaclusively conlrocling �' '� wifh licensed contractors to conshuct Ihe projen(Seo- � - nooRe55 � - � � � � �ion 7044,Business and Professions CodeJ. - _ � 'O 6 7 5.�� REOUIRED iOTAL SE1BA K - � " �"•��; CONSTRUC710N LENDING AGENCY - � Sei BnCe YARO Hwv pROv.LtNE wi�rA ' ;•. � � i`- , x I hereby affirm thm the�e is a construction lending agency for FRONT . � •�7�'��v Ihe performance of Ihe work for whith this permit is issued - c.�. ����_ �� � ' � O�� � 'S 7 (Set.3097,Civ.C.). " SIOE � � lendar's Nome CITIBANK P.l. . . ,. „� � , _ �.�;�;�'�`�1, . 444 S. FLOWER, LA 90071 P�-��a s ' 9 ce,mu rae : 66A.50 1DA""R"� " � � � - m Lender's Addrets . , ' . � .I certify that I have r ad this opplitalion and sfale ihat Ihe . lasvan<e Fee 10•5� �DM4 P/C M . . . ' �.�. . above informalion' c rrect.1 agree ro comp�y wilh all Co�nly Invesuganon Fee � � $ ordinontes an iar laws relming to building construction, _ Toiol Fee 675.�0 IDMq pe.m.M - �� . R and hereby th ze represenlalives of fhie County to en�er � ��� � � opon t - rlp'sqed property(or Inspedion �p�oTses. . . . . �� $75 .. . :..$35 . . . ', . . .. . Q � �P � SEE RFVERSE FOR E%►LANATORY LANGVAGE � Signaroro oi plicaM or Agen� po�e -. . . . . . . . . . � ._ . . . . . PLANS TO APPLICANT INSPECTOR'S NOTES .-OlF\P;It-11U11.UliN UI`.(',I.AI{i�1�10\ I hr.eby o44vm ih�i I om c.emp�-�rorn thc Comroctc�'s . .'.. , �- � . . � " : ' -, ', . -" ; '�� - ` � : . � � �Licensc Low iur the.follohing rea,on� �ISrc`7031�.51 . . To: ' . . . _ Retumed �. . �., , .. . .. ,. . . , ., �APProved � �� ..1lusiurscnrsdlnfs��iunv( J�:.�ln1'cit��nr.�+unh�ed�i�G No. Dote No. -�... Dvte�. .. ' "'.. . ... . . ••�,. �' rryurrec u prr (I n�(n�u.alfrn,i J e:drinoli.l�, . � - ' -.. .�, ,. � ::.., �n r �.-'-�_ ., ; , .. . ./niruricsrr�rt . ..(��� .� �, Y ---- ��or i ie. n r�!:its usuduu�,.�L��rr uirr.� ._ . . i- Ir: c,[: , - - .. . � ... rL���ppL:,rrrt/��r xu�d,prrn�it-to/i!e n si,pnrd.�e�tnn:�nf .-�-;:�. . ,. - ., �.� �. ... . . ._: :, .. ,.. � ._. _'._ _ "__"'_'_'_.. .-_'.. ._. _"__'_ .. � ,- that!c is licenr��Jpursrmrrt tri fl�r prnr i�iunc n/thr(:nn. f i�l�. .t� . . 4�.'fork I.i<�.•mr l.air(CFaffer')/(�n�umrn��in,q u•ith Sco- , r _ ,_. ._.._.__._ . _ . ... -._.__ � ._' "_ .__ .... _... OU /U' ' sn ��� n . . , . ` �. . ., . . tinn i0 u �rivun 3•�(fl,r!iu i .�� d! f � � �,� � ' .,,' ��.' �_Cnd�l nr tl�uf!�r i<rrr.irpt 11 crvJrnm� J f1�.F r f.,r r/,e r_ ._.. _._-- ._.. _-� _.__.._ _. . . ;_. .... _�..`.' _�. . . . . afl Rrd cxcmptinn.Anv rinladon./.)<it�orr I(�31.5 Fr �•:(. .t .. � ' _.. '� •Ye: ulro±o orApecelved-� . _.- __...'' .�..-:_ . _.._.. _'____ ..." anvappLrdnt/nra/�ermiftuh�c�lilbeappfrc�rnttnariril . . ,_ ..�.� q ' _ � . __ ' APProvals � proved � •....prxalltn/notmnrolfiaw/r h,�.,d.�dJdror�IS5nu1J� _. .. . . . .._ _..... . ....._... . �-' ' .' ' � ''' _ ' ____ �- . . - � � �� � -�- �� I,�5 owner o�ihe property,o�my nmploycos wnh • 1'io�.n Certlfim+e %��'''. � 1'l ���'� i'. � ..�_._ .. ._."'. "''"..._. .._._ �_� .____.,. . .__. ; .wugns os�he mpenso��on.will do�he worL.and . ._. . .___."'.. .. _. __ - � �_ '. , . - . , .:�.:-i �. .�. . ' � , . r soeco , . . .,ihe srcvcWre is�nai iniendedpr aifered for sde(Sec.7044) . , Flealih-Deportment .... ...... ..... ..� --_.- ___ _...__' '-'_.. __. ._ . . .0 .. ,.. „ � , '__,_. , � ._._.. __ __ ..__ �.. ,..U��rinrss�nJ Prnlss.vort�C J•�77m C t r turi�f.i.rnsi� _._..__ - __ _ ' . ___. . � .. �l.uu•dn��nn!4f�^Il In Yn rnoner er/�rr pr t�ud�n huil,h �.� F�re-0eportmen, --- --. __- ..- . .----- . -� ---- �:, c._.. . --or n •is d essu! i ��/nr irnp � U r n u u!,>do u l r r!. � .. . :I :p, `';;r,� ' � .1/rrou,�l,�Lrs rr�pL�}ee��.:f�ruriJ�.J.tlar sx.! nn.'� ` Grod�ny � � i�<.. 1 ,. '. . , �.. ' .,.� �- pmt�erttcxts�nre nni infrnJod <.r ��//rrrd nr inle. I7 , �. .. � �� , . .,�. i•;' '�� , �i.�, i. ;.: .. ,� , �' • ' . �Gnu�erer,1Ge building nrinrfrnnemcnf ic<a!J�rH1 rn nnE . .... .. . .�- ..- i _ . . .-",-. . . ;.:. : ....._ " . ... -� � j•ear ri!'cnnrpfrti..n,�tbc nunrr.hvifdr��u�i17 lure tLc �. Geolay cai� . - .._' _ _ __ _ ' . . . _ ._ hurJen nf f�rnninA�1Lu!!�n rfrd nut hv�(1 nr iri�prur�•fnr PedestrianProleuion. ,:.� .�. .V -. �� . .�.� ,�� . san/s�drf. �.' -. -.!� � . _ _ . . . . . tl � ,. . , r �Fence)ICanoPY) .: , ..,.` . . ___._ _ ___..".._'__."..._.._'_ ' _'_ � �I.asownr.r o(Ilir p.o erl .. � .... .. .. ... .�:� i .. ; ,.� ,P 9,�mcalus�vr.lycrntroo- ., ding wnh hcensed contractors io cons�ruct ihr.pw�ect(Sec. .. .. ,� . ._ . ..:�. . . ._. .. .._ __. . , . _ . ., SPec�al�nspecrton .�; ,. .-....': . - ,. -.�.--. '.�: : �: �s . ,_ v1,�aCJ�esnnl'e,,,lSt ai(7�urt / �.unrt��rrin �044) / (Conc 11Ma5onrY)IWeldin9) i. ... . . _'- �,_._.__ _. .. ' __..._. � . ___ __ l.r hP 1 /P P' . --�hu IJc�nFiv�prures�Lrreon,urid u•Lri-�nntrurtsJur:ii�l, , lot Dro�nagc ' ' ��. . ' � ' .��; - -.... ..• �-�._ - _. __ tc�u•if(� a innh✓ct r(sl lk:�nteJ p�rsusnf,In !1 r , . . __ ._ ___. .._ �.,,;« , , � - � .. - ' �� . . , . .. ' CnnlrurJuh l.i.ense l.a��/, . ..-. :-�. � . � „ ,,, ,.. .. - , Farking .. ... - �. .�.� ... . .. . ... ___._. . .__,_.. _.. .___._, ,,. .. . �. .: . . : [_I I am e p�under Sec .BBG.0 f ��th�s __ ___ ...__._'___.____..'_-__.. _ . _ � , , � reoson - � .. -,� ,., , . '_'_'.._..__._ . . _..__'___ .. . . ..__ ._ .., ._. .'" _ _.._,.. _"'..._.. .. .. _'_.�.._. ' _" � . , , Dnie Owne� . . . . � :_ .' �,.,.;, ' , ";., . � .__... ._. _ . � , .___. ...__ .... '..... . . , . Approvals . �ate - Inspadoh Signafura ... , , ,_ . , , , � � � � � � -� � �INSPECTOR'S NOTES�'�� -� tacafion- i. ._.. ._.. ..._._ . � . . . _. .._.' �J /y - .,�, Retbac4 8 Yords) � -" - l�CZd�Q7' IN.s��^-- '. - . , -1 i . � .—. i : . _,. -�...... ... „ . �.. � Foundo�lons � .,- ,.� . Slob �, . ��;t •-�, . , .. __.. . —__.._ __-.__ ...__._._ __�_..._.___ .' . . .� , . �n�,.. _.. � .. .. .. - � � Fromea� - � � .. ,.. . , � . : . � . . , ���a � . . . � . . �- ." . Energy Inwta�ion. ~ _ .. _.. __.....__' _ _.._- _. I ____.... '.��' _ . , .. . .. .l�L' � I �, . Laih:D.ywall:. � , /^ - !�. � __. ._... _ �_.. _ I ..,___'_ . .. , . . ... ��,�.a, FL � — -----. � ... Lo+h-Extenor � : . . . . �.. ...,� .. . ,. . . . --__.._._ ......_ _.. ._ '____-__- ._. � . . • . , ... ... ., ., .. I� _. .____ . ... � „ . HooseNumbe._ . . __...___ ___"_.� _._____. __. _.___ . � '"..�_ ____... , . . ,-.. - . . , . , Correu 8 Posied � . � � —.-: ..�.... .,. �. .. - , .• , ,� , . .,.. ,. ... , . �: .�.. . i Fmol.. � � , .. ,.. . „. , ..___ . _. ..__ ___.._..__ _-... ___ ...__. _.__. , � � . , _. . . .. . � ._;�. , . Enier on Front � .� � � � - _ ._. . . .. . . . . �� � . � .. � � � �: � ... , .� r. � -.. � .,.i\� 3l . .. . �� �t....�t,...�:,: -. :, �... .,.. ... .���(�� ...4\...- ��•-ti ,�� � . .... - �.. -. --'. �,. , _..._ .__' l