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HomeMy WebLinkAbout1546A 1547A (9) WORKERS'COMPENSATION DECIARATION . ' � � � � i � - � ^ I�hereby affirm iha�I hove o ce�iificate of consent�o=e�f � A-PPLICATIO�N�, FOR BUILDI NG PERMIT . `' I insure,or a centficate of Workers'Compenso�ion Insurance, u , or a certified copy rhe�eof�Sec.3800,lab.C.) COUNTY OF LOS ANGElES BUILDING AND SAFETY PolicyNo�3wc005-2��m��6 NATIONWIDE 61 A 2 a � Certified copy is hereby furnisbed. FOR APPUCANT TO FILL IN qooeess 23836 E. Goldrush Drive � Certified copy is filed wilh Ihe�couniy building inspec- BUILDING . - fion deparfinenl. � � ADDRE55 23836 E. Goldrush Drive Dare6-30-87 qpp�;�a„�THE ANDEN GROUP cirr DIAMOND BAR n 1 �oCnuTv DIAMOND BAR CERTIFICATE OF EXEMPTION FROM WORKERS' � � NO.OF Bi0G5. NE�aaESi - � � COMPENSATION INSURANCE � 512E OF lOT NOW ON LOT CROSS SIDIAMOND AR LVD + OLDE (This section need not be complerod if the permit is for one - � TRACT�i3435 eLOCK -- l07 NO.29 �ESSOR � , . hundred dollars�5100)or less.) MAP BOdC DAGE PARCEL owNekCHE ANDEN GROUP No967-9541 U ONE r�wv I certify Ihot in fhe performance of lfie work for which�his �1 NO. � ��� permit is iss�ed,I shall not employ any person in any monnar SVECin� . . so as to become subject to the Workers'Compensation Laws. � ADDaE55P.0. BOX 3329 � 1Do 1 e7 �ONDITIONS 0 arvCOVINA zia g1722 V DOIe � Appli[ant� � '� � ARCHITECTOR TEI. � � OTICE TO APPUCANT: If, efter makin �ihls Certi(icofe of DISTRICT GROUP TYPE FIRE VROCESSED BY xemption, you should become subject to the Workers' ENGINEFR DAVE SZANY AIA Ho.445-4073 r'� �Nu, � � � Campensatian provisions of the Lo6ar Code,you muzf(orth• qpDRESS �D '`� �� yV,J with.tomply with'suth provisions or this permit sholl ba . ._ � TEI. - ' STATiSTICALCtA55iEiCanON � APT. ONDO. � deemed revoked. . coNrRnaoH'HE ANDEN GROUP No. �ia ,{.. Z � LICENSED CONiRACTORS DECLARATION � � . . . . . ���.. Qa55 NO. DWFLL.UNITS—!_ I hereby offirm Ihat 1 am licensed�nder provisions of Chopter 9 ADORESSf,S 1�B�VE No.510560 � (commencing wi�h SeUion 7000)of Division 3 of the Business ond ��� 3��R�+P� � � , Pmfessions Code,and my license is in full forca and effett. �ITY CLA55 � BK � � � YALIDATION 50.fT. NO.OF NO.OF ; CHECK LlcensaNumbe�lO$6O Lic.CladsB " S�ze 263G STORIESL FAMILIES 1 ONE � - - � � VALUATION � ' � CommctoTHE ANDEN GROUP` po}e 6-30-87 oescRiarioN oF woaK ; N� �ADD s 157,000 �1.5 4,b A ❑I am exempt under Sec. GARAGE 445 SF . , _ i ALTER � . , #�'O • •2� 8.8P.C.for this reason .. �REGAIR = .. . . . . � �I •4 1 �i 5 9 Date• � USE OF � - � EXISTING BLDG. � �EMOI Signa�vre - .. ` . . - - AVPIICAM - - 7E1. � FINAL � ,��/ . • •4 1 6 5 9� OWNER•BUILDER DECLARATION PRINT THE AND NO. ' .DATE, /�d p _ - . , .I hereby affirm that I am exempt from the CoNractor's License � � � � -- , ���,� � "8 7 Law for the fol�owing reason(Sedion 7031.5,Business and AoocE55 AS ABOVE � F�NA�� � � Profes:ians Code): . . . ..- .. .. ..__ . . N . . . SY ��/,c<�, . _ /'^,^'7 BUILDING - _� I, as owner of the properly, or my employees with ADDRESS _ wages as their sole compensmion,will do the work and ��q�iTY ' � :� Jr Q,7{� the strucfure is no�intended or offered for sale(Section ' , 7044,Business ond Professions CodeJ. - � - MOVING � � � TEL. � � � ' �y � o' � I,as owner af tha property,om exclusively controcting CONTRACTOR NO. � .- �i • with licensed tontractors to conslrucf the pro�ed($ec- ADORESS � " �� I °�7 rJ.Q� tion 7044,Business and Pro(essions Code). r_ i� ..`� � CONSTRUCTION IENDING AGENCY - �- �- �gq�K YARD Hwv T�TApROR IINE wiorH � ' � ' -' ` .. '� ' � • •6�M O O� I he�eby affirm�hat there is a consrruction lending agency for FRONi � ' � � the performance of�he work for which�his permil ia issued � P.i. 'l�'";-'� . ��' 7"— Q Q.� � —8'] ($ec.3097,Civ.C.). SIDE �.�. 7�, �. � . v.i. � ;r �, _. Lender's Nome CITIBANK � " IDMA Ref.M . .':t .' Lender'i Addresi 444 S. FLOWER. LA 90071 a.c.ree s ve,mu Fse 664:50 � ;;�1 � I certif that I have reod lhis o limtion and staro fhat the . . 1�.5� ; , . Y PP laeuance ise IDMA P/C M .. . obove InformaY Is wrrect.�agroa to comply with oll County Inveetiqatlon Fee - $ ordinanees ote laws relating to building ronstruetlon, ,. � - Taeal Fss 675:0� �p�,qq perm.M � R ond here o rize represemotivea of this County lo enter � � - - vpon Ih ' d propeny for inspectlon pwposes. T�n T.�p o � 3ZCRlYlRSF IOR�X►LANATOIIY LANGUAG[ SiqnaNre ppli<on�or Apeni . .. p�e � .. . . . . � PlANS TO APPLICANT INSPECIOR'S NOTES ,, UL1'tiP;H•ISUILI)IiH,�JIfCI.ARA�1�lU1 �, . ; ,. .. � . �. . � ,,.. , . . :;[ t�., ',L :::lit'e se�lawf f 'Iii�ei�fol��v.e�g`ir���o�'`�(S�c.n'7D3i�5i i � To: ', . � . Retumed ! . '.., i . . , .� ., '� ' . . �APProved � •. lA�sinresnnJlr7�rsinncCnda:Anyartl'nr.��un(cu•Gicl No. Dme No�, ' 'Dafe..."_ . .. .�- . ..� � . � .. , �_. �. _,� „ � , rcyurrcc�prr ttt t ,ruf urt u!e f r -d ,(ulr, - - ----- . . -- ..j..0 ar+v.�rructun.��j�n,.ri�.t:uc;ru[..dl�n•�yurrre '. . .'-;: ' �,,:1 ... C�£-.,'�� `.. -.� �:'.� I 1 . I I,i � .. 1hc a/�/�li.,�nf fr r�sr:.h p niit!n/i(e a siqnrJ�.ae�tvu���nl ,-, ; .�, � �r , . . . � . . ._ . ..__. _ :.___ _ . ___._.._ ....__... ....,thatbc.islitrnsrJ.(�ursu�n�tu1/,r/�r.�ri�inns�i/Ihi Cn.r• .. __._. _. .__ .:i t � er�.tar's l.i<'ansr I au�(CAap�er Jl(�u nuvuin,�u�it6 Jre- � ..__.'_. _.._. _ _._ . . ':: ...__. _'1 _ _ _ . ' f f !3 � � JP / ,_.. __ _...______ . __, ..J'. . .._.. -_.' ._. _ _ �� ," __.___ _ _ . •` .__ __. _'�(.iulr/nr,4J�a�l`e'�c�i.unrpt�tJrrrrlron�anJ1[�eAns�.cfrrllr ' ._ _ .�,. �.,.. -. ; _ ._ _..____._ .___. . ..... ._-.. '_ "_..: -- . _ u!lrRvJ r.rcm(�firm.�)rtV rrofdtriu�r/1 finx�.i f17 L9 F�� .,.�.�,.�_� , r:�•.I,� �,' ' ,'Requlrod':... � ��. . .�_,� . ��. .. __. '. :/:'.��.�.. . ... ._..... .. '___ . - arn�pli:�nf/orurcrn�itu�bjcrtr!l�rappb�an�ln���re! Appro•als -�� - Dato Rofeivod ��-pcn�11'��l nnt mnrr liwn/rrc brrndrrd d,�1r,,,�Is5r�o1.1� - , � .. � __ Yos .No or App oved� ... . . , . ' , - . . _ -__ ._-. _. �.__..__._ _�_ �. • - - . . . .• ��I I,os owncr of Ihe p oP�rty.o�my cmp�oyc�s wi!h V':�.e.Crr.i���ca+e __r%• �� � ,.�.� � �����:�' .. . . ... . ..... - . . -__ .....__ .,��wn es as�)he sole compe.saiio�.will de the wo�L.and , . ' _. .. _ .. ... .,;. ._ � '..� .. �.,. . , ,. � .. ,. ��si�uc�ure s noi' � 1 ) _ .. �. � .._. _ �'_ _ _ 9 , . _ ..--. -............ ... ended o o(le td(or sale Scc 70-fA • . Heol�h Deparrmeni.__ ._ ' .. . ..,' -. --- .. ..-. �$��sinass an'1 J r/�is'nue�( f 7!�f:ontr,�rior:a!� nse ' ' .___ __'_' �...�_ _ __ . . __. . . _�; .. f.air Jnrs n��t upp7v ro.+ri m�n�r uJ frnprrle trL,�l�ui/Js Fre-Depu.im�nl_- ___. .. . -__.. __ __. . ,_.._ . , . . . __n / _''s r �a d u rrx nri: urnc� . i .� ...� , � .:,,.:-� :: ..;, �.;. '��. � .., , ... � .11��u,�L"L�isr ni�n r�npfutcrs r pruurl,l��tJ>.�t/svab/r .. . " - - ,.-prot�emrnfr�rt�e.nnt iNrnded ur:uJ/rreJ/��r.s/ f� • G�ncling _,..�,, � '.��' � i `�. f.`f, �, '...�`, I . .. � �,i...(�rie�rt�rr.76e h��ilJink nr im)+YPYI'R(Pq!!t!O!d tr r!/nr une , - _.� - , '. _. _. i:'J..�'. "�.. ,�'�:____�.-. , . :��;.' __ _ _ ..__ _...__ . .. ._: ... : . . ..'._' - yeur n�iompletinn. tL�� u n.•r.l,rdfJer�-u i!f larr"�eGr . 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P . , � ,.. , . . . _..... ,- . .. . - - • -c. �f„�:,,,..�r.«,�,�r.,,�,�. _, , ,._ .,. . , , t __�_ ----- _...,.. Pa�kin� ' . � ' � . ' [; I am r.xempi under Sec. .�.BP.C.fo�ihis - . ., ., , .� —__ . -.-'-..�'.< � ', _. �. -. .______-..____ _.._..__. i reason j. . .. .. . - �i _.. ... . .__". __' _.___ ..._..__.' _ _.._. _". _......__'_ '_"'____ __._.... " '_r �.. .'. -. .. _.... � Dale Owner �. ; .. . .. , �. �.. . ,...,. ..�' 'i.. , ___'_'_' _.. ___.... .____... � aPProvals Dafo f Impactor's Signaturo . . �� . � ,.. . . .. . ... .. . . ��NSPECTOR'S NOTES-'�- : Lo<anon_ �. _. ._.________ ._. _._. :. ., ._ .. (Seibacl 8 Yords) k. . p. ___ ,_�_ ,. . �.. .,.. >':- _ .�. __ . �. } . Faundorions � .,. ' �� .. .,.� ,�.. ,. . . . . Slob . . , . .,. _ ' _.. ., '.. ,.> ; . ._._._ _..___ .. .._._'_._ _ -__. _ _. . ,..,� ,...,......- . �.�.�. ,.. ,. . .. � � . , y,.., „ Frama _2�I�O . . . . , . . .. _. � , . .-. . : _,.. . . . ... 1�,� . .. . _.., . 1 0 , Ener9Y 'L � p� �Cl ./- ._ . __..-:_. .__'. � , . .. - .,� _ . . .. Insulo��on ' _ � -..... .,: � � . . . . ... .�,., ... ` O� _ La�h;Drywall. � � � . --... . .. . ..-'-_ - ___-- ._-• ,... . ,� � �, .,. � ��,e„a, 2-l8-YY; - —�.��� — --- � , Laih-Extenor +�.�x 0��, , ., I .. . � . ... �., .. . . . ___ _._ . ...._.._ _ �. � .. ._ .. _�. __'. '' ' . HouseNumbe._ ._. ._ .' _ __—_.__ .. ..__._._. ,._ __._.._.. . . . �.. .... ... � . . CorreU 8 Fosied � � . � �l' � . .. . .. .. .. . . -. .. .. . ,.�, Final. . __._. ...__. _. ...._.. . .._.... .........'._._ . . . .,. . . _.._ . .._ .. ..�_. 1 �..� '� , � , '_..i� �: �r� 'c ...� � �. . . �. EnIP,on Fronl ... '�� '�' . .`. . . . .• . . �.. � . , . . ...� . �... . . .. .. . _. ... , . , .. .r - \�� �. 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