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HomeMy WebLinkAbout1544A 1545A _ _ _. .. _ "_ . _ . _. _ _ _ WORKERS'COMPENSATION DECLARATION � - �.�� � � �� � � � � � � '� � � I hercby affirm Ihat 1 have a ce�tificme of�o�,e�,,o,��f � --- - � � qpp��CAT10N FOR BU1L'DI NG PERMIT insure,or o ce�tifica+e o(Workers'Compensa�ion Ineuronce, , or a cenified copy thereo4{Sec.3800,lab.C.} COUNTY OF LOS ANGELES BUILDING AND SAFETY PoltcyNo.73wc005-2�&rr�J6 NATIONWIDE � Ceri�fied copy Is hereby fumished. FOR APPUCANT TO FILL IN i suuoiNc ADDRESS 23844 E. Goldrush Drive � � Certified copy I�filed wilh Ihe county building Impeo- �"���� BUi�DWG � ��on deporlmeM.� � ADDRESS 23844 E. Goldrush Drive Dote6-30-87 appt�canr THE ANDEN GROUP cRv DIAMOND BAR ziv 1 �oc�.urr DIA1fOND BAR CERTIFICATE OF EXEMPTION FROM WORKERS' � Si2E OF l07� t O�w onei io 5� ! � cRossSstDIAMOND�BAR BLVD. + GOLDEN SPRINGS � COMPENSATION INSURANCE � (This section nced not be completed if tha permif b for ona � ASSESSOR hundred d011on(5100)or leas.) . Tancr 43435 BLOCK LOT NO.28 MP.P$OOK� � PAGE DARCEL � TEL. US N MAP � —�"� owNertTHE ANDEN GROUP- No.967-9541 I certify Ihaf�In the performance of the work for whlch this _ NO. TU permif is Issued,�sholl not employ any penon In any manner � SaeCiAl � - . �� � � so as to become subjett to tha Worken'Compensotion lowo. aooaessP.O. BOX 3329 �OQdC7 [onroiiioNs 0 � arv COVINA zia 1 22 v Date � �APPIiwM . �. � .. .. ... . � . . � ARCHITECT OR TEL. �1QTICE 70 APPLICANT: It, afler moking�thts Certificote of DISTRICi GRDUv �E FIRE GFtOCE55EDBv � xemption, you should beeome subjeet to the Workers' ENGINEER DAVE SZANY AIA No.445-4073 �j � ) Compensation pravisians of Ihe labor Code,you m�ff fo��h- q�QE� /� /\-� �'�/ � w wiih comply wNh svch provisions or this�permit shall 6e � �� � � � LL' deemed revoked. - � � . � TE�• ; STATi511GAi CtASS�F�iON A7T. NDD.� Z coNTanctodrHE ANDEN GROUP No. ..�! IICENSED CONTRACTORS DECLARATION � , � � � - � �� ���.- C(ASS NO.�� DWE�L.UN�TSJ�. - I hereby affirm Iho�I am licansed under pravisions of Chapter 9 ADORESSAS ABOVE No.510560 ��R�P (commencing wifh Section 7000)of Div�sion 9 of the Baai❑ass ond . . . . ..._. . ���, .. . Professions Code,and my licensa is In full face and effect. Cii� � ttA55 � BK � �- �VALIDA710N�- �icense Num6eb 10560 � sa.Fr. Ho.oF No.oF CHECK � lit.Closs B SIZE 2634� sToeies 2 FAMIUES �1 ONE � �i N� VAIUATfON. . . `1 ���A ConfrattorTHF. ANDF.N rR(1jiP pa}e F—�n—�� DESCRIPTIONOF WORK S LS7�OOO �ADO , . �� • • •'2'� ❑I am exempt under Sec. GARAGE 64 SF � ALTfR . B.BP.C.for this reasOn . REPAIR = � � •41 fl 5 9 . .. . . Dafa: � FXIS�NG eLDG. DEMOL ❑ s •4 l 8 5 9 c=.> � Signature . . . . �.. . �� APVIICANT TEL. FINAL �,r�/ . OWNER•BUIIDER DECLARATION PRiNT NO. ' .. DA7E � D Y� ..� . _ 0 9,1 l�8 7 �I he�eby aifirm ihat 1 om exempt Irom I�e Contrac�or i Licensa ADDRESS AS AB VE FiN�t ' �� � � �, Law Tor tha fallowing reoson{SeUion 7031.5,Business ond /j � - - � Pmfesetons CodeJ: . . . . ... .. ... . .- !y ����-i-'� . - . �`^� ' BUIIDING . . �� . � J I, as owner af Iha property, or my employees w71h aD�RE55 � wages as the�r sole companeation,will do the work and ��q��iY `� , �� J�Q.Jr A the struuora fs not Inrended or offered for sale(Secfion � � 7044,Bueinefs and Professlons Code).� � � - '`- MOviNG - - � � � SEI. �� � - � ,❑ I,as owner of tha properly,om exclusively contracting CONTRACTOR NO. �. ����" • ' � � with licemed conhactors ro construct�he pm�ect{Sec- ' ADoaF55 �- I •b 7�rJ.Q� tion 7044,Business ond Profeuions Coda). � ' •' � REOUIRED TO AL ETBA K .`'\ . ,7,� �,\ �':' � ` CONSTRIICi10N LENDING AGENCY � -���� SEi e.4CK YARO NWY DROP.UNE W�o7N � � � •6 7 5,O O u 1 hereby oHirm thaf lhere Is a conehuction landing ogency for fRONT ,;i t� � ��,`j. � ��he performance oI 1ha work fo�which lhia permit is issued �- P.�. � - � O 9,� ��$7 (Set.3047,Civ.C.). SIDE t. lendar i Name CITIBANK P.t � �.�' ' �'�' � v.c.F�s s 418.59 . r�.mu rss 664.50 �DMA Ref.N � - �� = lender's Addresa 4.4.�5- FT.l1WRR� T.A Q(1l171 10.5� � , � f 1 certify that I hove read thts-applica+ian ond afate Ihaf Ihe . � - Issvunce Fee � LDMA P/C N � ' obove Informo' is mnett.I ogree to mmply with oll County ���ef�igm�ion Fee 675.�0 � , o�dinonces d late laws relating}0 6uilding construtlion, Totol Fee IDMP,Perm.N - ond here o riza represaMofives of ihis Coonfy�o enter upon 1h - ' ned property(o�inspecti0n purposes. . , - � Z _ LDM11 $75 $35 , SEE REYfRSE FOR El(►UNATORY IANGUAGE�. � Signarure of Appl�cant or Ageni � � � paie � � � ' � - PLANS TO AVPLICAN7 INSPECTOR'S NOTES �.,OLS;\Ii1LNUll.1)IiR.UGCI.nk:1'170� I hmeby afll ' fi;o�i I nm . emp��'tro �I c�Con!rectnr'o- To: 4' I.� � .. . Returned�' .�� . � ' . � ,' � . .�".�License.Lmn•..for ehe,.foUo . g .aron I <'c„70�1�i1 I. . . �APProvod - �Ilr�nurssnndlr�I�aannsLnJ�.An�.citlru.tnrnfv�il,id� r::. No. Dofe ' No. - `.-Oate-... .. " ., •.. . . '�.�1 ,.. .. �. ,. rey ..+f�rr 7 r t nnfn t oft r,� rJ �, drninli�h. . .. :.. . . . . __'lirrtf tranl•Struciuri•�hritrf�i�Isls.�ti✓ni[:ulsi.rfy�tirt�� . -:�1 � ' ,. , .,�.. I.�i�.:.:i �!r uppfi.mit(ur urlr prrniit ro fifr a si,ineJ xtuterrri�ni - -- .lGuf Lr isliunsrJ(�ursum�f!0 1Ir<�f�ruricinrta o/fhe Cun; �.: -�� �� r �.,;� ' �tru�lor'xl.i�rns���l.au(Cl,apfrr/llcori� r �r�Girith.S���- , ,.--, .1 c..� . . ,_. ._ .. , __ , � . . . .__. __.. _ . _. . _.-._ . _ -_�___... ___. . —.._ . : ._.' ______' -. _." .. ---" ---"� lron?UOOJ.,JUi+�i�ion3?/d�rl3usin�sc,<ndPruJ.•<��„n. � ; .,:.);� .,: •_ �.. �, "�•: • . `�•�. '���,�.i�l '� rG�J�Jnr1La1(dis�'senrptlberefrnnranJlbrbnsia/nrlhr __.._.___."_.'.__._. .___ ._ ..'_.. . . _"_ .�. ___.____ ._��.. � '__'____ . _ �.�_.'.�..._. __'..__._. �_ . ._ . . �!!�¢rJexev:ff n.,:lnv�erolahnn/Jechnr�JU37.Sh�. 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"��' ' ______._.__ ._... _ _._ . . . . .�. . . .. �Uusinest unil Pr.r/iscivric C �!:Jlri•C tr�c tnr's l.i:rnsr , � HeolthDePanment .._"_. ___._.... .._ '.___t__ ... _' - . _ . :_. __._._.--. . . .-: ., . , . . . !.0 i d�rs nut�upflr ro�en nu•nrr i�f prnprrtt•��rL.�hui[Jc • , ... • .. �.,. . ' orra f!errnn,unJ�!�dncs�u!�u•nrk l�inrsr/ r Fire OeOanmen�. _...._. . _. ._ ..'_._ _____. . . ._ _ .. . .. - '.' �� _"_ " � . ��� . r .r ,�..,�: `,.i� �.� ",� , .., ' .. .':.�.�: : . . �.4b l�is.:��an ernpfu,l .�.J�����iJeJ-:tlot su�l.im.--•_ !/` Gr�d ng .� , � z..f+rnrcmenls ar.� nnt in(ceJeJ ur,!ffcre{!fnr,.sulr.../. r �.�� - . . . ..' lrn�rrrrr,tLe huildinX or irn)nni�cmrn�rs guld irill i�r nnc ; , ,. . . _. ' ,_.... ..._.... ._ .. _ _. _. 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(Cenc.l(MasonrY)(Weld�ng) ' ��- .. . . . � � . _ •. ,. . , . l.innac I.aord s nnf dpff�tn qn ure�rt r.//�rnfertv u�bo ,,. . _. ____ _ ---_ , __ ---Rarrd„�r p��„�,rf,�.�-,�n..�,�<i�,t„� 1 ��tatra�ts ,.i�,.r� tetD:mnnqe .:,- i'�:'.� ..-... ... ... - .. prn�rcis ur'd,a trurhrr(c)licenmd`.p��rsuant fn �Ir<� . ��,: .. ,. ....__._.�-. ..... ... ._ : ..•iin '� ,. .._... .. ..._. _, ._. _ , . . ._ � , �. . '�_Cnntra:�nr'sl.iceriar I.ai�J'"'..,.._��..__.._..... � �� - � . . � ,. ... ,.. .. � . ._..p._.. .. ._. . .. �_.r.�-�. , ,., - Vorkmg . . . . . .."�-'-'.. ..-�----�"-�- ---- . .. . ..__' �]..I om�xem i undcr Se<. B.RP.C.for Ihl� _.___ _ 5 �.. � -_ __._. _ -__'_'..._'_-'_' ._�_....;., . � - "; . . . . reason • � .. .. _.__._�.._.__._. ,.�_.._ _._.__"_ _'_.. . .._.. .__. � � " Date Own � � . . . _. . . .. -.�.:'.�'. ��„i_ , . ,. . . .,�. _ . . , , , . . ._'_ .___�.- -......__ _ ' . . . .. . .. , ,� , .._ ... ,,, .. __ .._� .: ..� . . � �.. � ..� Approvals Dote la�pactor'c Signatura�� . '� � , ,- , - ��r, ,�1�SPECTOR'S NOTES-- �� � � loca'ian._ .. . � . . . . . __._._._._.... .._.'._. .__. Q r� � (5eiback 8 Yordsl ...�,'L-�0 - �9-�-�ALf�Y -�-� "� _ . . . . . . '.. .� . ;., , , . . Fo�ndo��ons '� � '� � - ,. ;. ����:,�,. . �.. :.,., . Slab . . . . .. . . , . � _ � . Frome �Z7'P � � '� . � .. . ... . � - . . . � . ...�. � .��. . . � e�e,gy i�su�a-o� .L„S_ � ---. .....-- - - -� ' � . . _ , .- .�-.�. " . . - . La�hiDrywoll-. ' � _..__ _- .___'.. .... .. _ :_. �_...'._'_ . � ' .. _ ��,«,o. Z-►��� . P-�,�-_ ____._ . , - - �a�h_EK«„o� ; _ _— — --- --- _ :_�:.:., . �iz�� �,�, , . , __ , � . ... . Haose Numbe._- : .. ___. . _�.______.. _....._.. . .-.... ....._ _.',i �.� � �� � , � . Gorreci B Posied �. �1�. { . . _...__�_. .. _._ .. . � Final_ .. ._._. _ _.__ _� .._�_... .. . - �. ,.___.. ��.:.__. .._._ i �_.'_.. � . . . . .. .. _ _____.___. . . . 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