HomeMy WebLinkAbout1502A 1503AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.) '
Policy No. 73wc005��An_P.016 NATIONWIDE
M C; oified copy is hereby furnished.
ElCertified copy is filed with the county building Inspec•
tion department.
Dare 6-30-87.. Applicant THE ANDEN GROUP
CERTIFICATE OF EXEMPTION FROM WORKERS' '-
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one -
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation laws.
Date Applicant � - --
IOTICE TO APPLICANT: If, after makingthisCertificate of
(N
;emption, you should become subject to the Workers'
.bmpensation provisions of the Labor Code, you must forth-
wllh 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.
License Number 510560 tic. Class B
Contractor THE ANDEN GROUPDate 6-30-87
13 1 am exempt under Sec.
B.BP.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code): -
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 sale (Section
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).
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.).
Lender's Name CITIBANK
Lender's Address 444 S. FLOWER, LA 90071
1 certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and to lows relating to building construction, -.
and hereby o ize representatives of this County to enter
upon the v d ropery for Inspection purposes.
'Signature o plicant or Agent Dare
APPLICATION FOR BUILDING PERMIT
75/A COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING ADDRESS 23743 E. Goldrush Drive
BUILDING
23743 E. Goldrush Drive
ADDRESS
CITY DIAMOND BAR zip 91765
LOCALITY DIAMOND BAR
SIZE OF LOT NOW ores LOTS• �
NEAREST
ROSS ST.- DIAMOND BAR BLVD. + GOLDEN SPRIN
11ACT 43435 1 BLOCK LOT NO. 14
ASSESSOR -
MAP BOOK PAGE
PARCEL
OWNER THE ANDEN GROUP NO. 967-9541
u/5`C�/,zONE
—I
Ion LI) -0
NNoP
ADDRESS P.O. BOX 3329
SPECIAL
CONDITIONS
CITY COVINA ZIP 91722
- - -
ARCHITECT OR DAVE SZANY AIA TEL 445-407
DISTRICT
GROUP
TYPE
FIRE
PROCESSED BY
ER
/
CONS
ADDRESS 314 N. FIRST ARCADIA 91006
THE A19DEN GROUP 1E1.
CONTRACTOR NO.
STATISTICAL CLASSIFICATION
CLASS NO..DWFLI. UNITS
APT.
NDC.
ADDRESS AS ABOVE Np. 510560
. tic.
SEWER MAP;
CITY cwss B
- BK PG - - -
VALIDATION
So. FT. 277 _NOSTORIE ..2 NO. OF 1
- CH CK
VALUATION
DESCRIPTION OF WORK SINGLE FAMILY
NEW
ADD
000
$ 164,000
,2
-
1 5 0 2 A
.GARAGE 643 SF.
ALTER ❑
REPAIR
❑
$
4 • • • + 21
I-43 1.08
USE OF
EXISTING BLDG.
DFMOL
-
FINAL /
DATE ?��
FINAL
�
• 431.08 .1i
0 9..1 1.—,87
APPLICANTTEL.
PRINT THE ANDEN GROUP NO.
ADDRESS AS ABOVE
PRESENT0y
BUILDING
ADDRESS
'
- 1 5 0 3 A
LOCALITY
MOVING `' .'TEL.'
CONTRACTOR NO. I
• • s •.• 1
ADDRESS_
f'.
J•� ", —
I • 69600
REQUIRED TOTAL TBA
YARD NWY
SET BACK PROP. LINE WIDTH
�'�~ _,
• •x,96006
09.1 1 —87
FRONT
VI.
SIDE
SID
tDMA Ref' R
431.08 685.50
P.C. Fee S Permit Fee
Issuance Fee
LOMA P/C R
Investigation Fee
- Total Fee 696.0(
LDMA P•rm. M
LMA $75 $35
SEE REVERSE FOR EXPLANATORY LANGUAGE
0
S
r7
