HomeMy WebLinkAbout1508A 1509A (8)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
-
•insure, or o certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.) -
Policy No. 73wc005-2c7 �9i.6 NATIONWIDE
Certified copy is hereby furnished. -
Certified copy Is filed with the county building Inspec-
tion department.
pate .. 6-30—plicant 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
kemption, you should become subject to the Work...'
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 Number 10560 Lic. Class B
ControctorULE ANDEN GROUP Dote 6-30-87
I am exempt under Sec. -
B.BP.C. for this reason
- Date:
Signature
OWN ER•BUIIDER 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 Nome CITIBANK
LenderiAddress 444 S. FLOWER, LA 90071 _
1 certify that I have read this application and state that the
above Informati is correct, 1 ogres to comply with all County
ordinances ate lows relating to building construction, _
R and here6 a rtxe representatives of this County to enter
upo h property for Inspection purposes.
Signature pplicont or Agent - -
APPLICATION FOR BUILDING PERMIT �]
7c COUNTY OF LOS ANGELES WILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING ADDRESS 24002 E. Goldrush Drive
noon ss 24002 E. Goldrush Drive
CITY DIAMOND BAR zIP91765
ITRAcT
Locaurr DIAMOND BAR
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
NEAREST
CROSS sTDIAMOND BAR BLVD. +- GOLDEN SPRINGS
43435 BLOCK LOT NO. 27
ASSESSOR
MAP BOOK PAGE
PARCEL
TEL.
OWNERTHE ANDEN GROUP NO.967-9541
US ONE
MAP
MA /] $
ADDRESSP.O. BOX 3329
OQ%[7
CONDITIONS
CITY COVINA zip 91722
ARCHITECT oR DAVE SZANY AIA No. 445-4073
ENGINEER
DISTRICT
GROUP
e-3
TYPE
CONST.
� t
FIRE
E
PROCESSED BY
-
ADDREss314 N. FIRST A ADA91006la
TEL �
ANDEN GROUP No.
STATISTICAL CLASSIFICATION
1
CLASS NO. t✓y DWELL. UNITS "J
ADT.
C=coNrRAcrDRTHE
ADDRESSAS ABOVE NO.510560
SEWER MAP
LIC.
CITY CLASS B
BK. PG.
VALUATION
VALIDATION
SIOZE� 2774 S ORIOES 2 INC.F MIOLIES 1
ONE
DESCRIPTIONOF WORK SINGLE FAMILY
NEW ®
$ 164,000
ADD
GARAGE 643 SF
ALTER
,
-q1 5 0,8 A
REPAIR
DF MOI
9
FINAL
DATE
e• • - `Z 1
( • Q s3 �. d 8
e • 4 3 10 8 5
USE
EXISTING BLDG.
APPLICANT - TEL.
PRINT THE ANDEN GROUP NO.
ADDRESS AS ABOVE
FINAL/f
By
09.1 1 —87
PRESENT
BUILDING
ADDRESS
tOCALITY
MOVING
CONTRACTOR NO.
& 1 50,9A
-
ADDRESS
I " E1 -S'-
fr • • e e • 1
REQUIRED TOTAL SETBACK
WY
SET BACK YARD HPROP. LINE WIDTH
, ,
( p.�
. Y- (• S.'t ,. r •�d
( -69600
• e 696, )0aE
PA. ONI
P.1.
1
LDMA Ref. N _ .-.
0 9, 1 1-87
P.C. Fee s 431.08 Permit Fee 665.50
111,
F,'
10.50
Issuance Fee
LDMA P/C M
-
Investigcnon Fee 696.00
Total Fea
LDMA Perm. M -
LDMA $75 $35
SEE REVERSE FOR EXPLANATORY LANGUAGE
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