HomeMy WebLinkAbout1512A 1513AWORKERS' COMPENSATION DECLARATION
I'hereby affirm that I have a certificate of consent to self
insure, or a certificate of WorkersCompensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No.73wc005-2Z2fRQ46 NATIONWIDE
Certified copy is hereby furnished.
Certified copy Is filed with the county building inspec.
Ilan department.
Date6-30-87 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 ($100) or less.)
I certify that in the performance of the work for which this
permit Is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
(—NOTICE TO APPLICANT: If, after making this Certificate of
! ixemption, you should become subject to the Worker.
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Numbe>510560 LIc. Class B
ControctorTHE ANDEN GROUP Dale 6-30-87
I am exempt under Sec.
B.$P.C. for this reason
Date:
Signature -
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law 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
I certify that I have read this application and state that the
above informat4 is correct. I agree to comply with all County
8 ordinances thotate laws relating to building construction,
and here rize representotives of this County to enter
upon th a ed property for inspection
Signature o Applicant or Agent - - pore
APPLICATION ;FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
ADDRESS 23746 E. Goldrush Drive
BUILDING
ADDRESS 23756 E. Goldrush Drive
CITY DIAMOND BAR nd91765
LOCALITY DIAMOND BAR
- NO. OF BUDGE. -
SIZE OF LOT NOW ON LOT
NEAREST
cRoss sTDIAMOND BAR BLVD. + GOLDEN SPRINGS
TRACT 43435 CK LOT N0.34
BIO
MAPSBOOK PAGE
PARCEL
oWNERTHE ANDE14 GROUP No967-9541NO
UWOL•JE
lode a
MA % 3
AODRESSP • O. BOX 3329
CONDITIONS
CITYCOVINA zip 91722
ARCHITECT OR TEL.
DISTRICT
GROUP
TYPE
ENGINEER DAVE SZANY AIA No.445-4073
CON
ADDRESS 14 N
LL
TEL.
ANDEN GROUP NO
STATISTICAL CLASSIFICATIONCONTRACIOITHE
CLASS NO. DWELUNIT
LIC
ADDREssAS ABOVE NO.510560
SEWER MAP
-
- LIC.
CITY CLASS IR
BK - PO -
VALUATION
VALIDATION
:21 5 1.2A
SOEFT.2774 STORIIEES 1 FAMItIIES 1
CONEK
DESCRIPTION OF WORK SINGLE FAMILY
NEW
®
: 164,000
oil.•
• • •21
ADD
GARAGE 643 SF
ALTER
Q
1.431.08
REPAIR
t -
• • 4 `3 1.0 8:1
USE OF
EXISTING BLDG.
DEMOL
FINAL
O q, 1 1` S%
APPLICANT TEL.
PRINT THE ANDEN GROUP NO.
y
- DATE - / f 1 -
- -
ADDRESS AS ABOVE
FINAL
BY
FREMINT
BUILDING
ADDRESS
.
1 5 1.3 A
i • , • • • 1
I • 6 9 fi Od
LOCALITY . - - •
MOVING .. ( .., ` .. ` TEL.
CONTRACTOR NO.
s -69600'
ADDRESS
.._., t. L. t . I
9. 1 1 —87
SET O BACK YARD HWY TOTA PROSETP LINE WIDTCK FROM H
FRONT
P. L
_ _1, a •. -.
LRAM a°`'
SIDE
P. L.
P.C. Fees 431.08 Permit fee 685: 50
10.50
1,. ... ce Fee
1DMA P/C N
tnvevigation Fee 696:00
Total Fee
LDMA Perm. N
LDMA $75 $35'
SEE REVERSE FOR EXPLANATORY LANGUAGE
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