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HomeMy WebLinkAbout0726A 0727A (4) „ r.�KncR� �umvtrvSqilON DECLARATION ���,.1 a��! + � �� �� I hereby affirm that I have a certificate of consent to self ��1 �r_ g�-s �1�_yw�� ��g p� p �i� � � �•� ,••arer:if;:c;�o£�:+orksrs'ComN�rs�fionlnsurance, �� ��rd/��0��� ■ V� i./'�.0-'���-�1/ ��-���� � or o ceriified cop ihereof(Sec 3800,�ab.C.) � COUNTY OF LOS ANGELES -BUILDING AND SAFETY � 8.�-CK-956-�104-CPA , Po icy No. - Company 1�t'717 � Certitied copy is hereby furnished. FUR APPLICANT TO FILL IN nu�to�N<; aaoRess � a Ceriified copy is filed with ihe county building inspec- BUIL�ING � I flon department. ADDRESS 24219 H' d LOCAIITY I NEAREST ( Date 11/2/83 qpplicant The Anden C�'oup arr Da.ltmnd Bar ziv 91765 ceosssi. H'i h Knob & Golden r'in s '�. CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OP 6�DGS. �ASSESSOR � . COMPENSATION INSURANCE SIZE OF LO7 NOW oN l07 MAP BOOK PAGE PARCEL (This seciion need not 6e completed if the permi�is for one USE ZONe MAP �- �,N��C hundred dollars($100)or less.) TRAC7 3 9LOIX LOT NO. NO. �t”?� T L. SPECIAL ,'Y I certify ihaf in ihe performance af the work for which this OWNER (3 '] _ CONDI710N5 fl, permif is i55UeC1,I shall not employ any person in any ma�ner DISTRICT ,GROUP iYPE FIRE PR ESSED BY � so O5 to become s�bject io the Workers Compensdfion Laws. ADDRESS ' - CONST� ZOIyE ��—J � arr San Dimas z�P 91773 `� '�� � � O Oate Applicant STATISTICAL CLASSIPICATION APT. COND0. �� NOTICE TO APPLICANT: If, after making rhis Certificate of ARCHITECTOR ie. �/ xempiion, you should become subyacf to the Workers" �ENGINEER DdUP_ 2 45-4 7 CLR55 NO. 4C=' OWELL UNITS r � .:ompensation provisions of fhe Labor Code,you musf for�h- pDORESS 3 - SEWER MAP . �� wiih compty with such pravisions or this permit shall 6e m deemed revoked. � TE�� VA41�AT10l1 - . CONTRACTOR BK� P�, . LIGENSED CONTRACTORS DECLARATION ���. I hereby affirm ihoi I om licensed under provisions of Chapier 9 q00RES5 629 Covina Blvd. � No. 371580 Vp1,UAT10N (commencing with Seciion 7000)of Division 3 of fhe Business and ��� ,y� Professions Code,ond my license is in full force and effect. CI7Y San Airro.s CtASS � S � ���°y ,_► � -� License Number 371580 �ic.class �siz�eFT� 1570 TOR ES 2 FAMILOIES �. � CONEK $ Coniratror �e �111dEI1 �011p pote �-�-�2�83 DESCRIPTION Of WORK NEW � �I am exempt under Sec 5711 le fclS[LiZ hOI[� �ADD -° - aLTER (�}'� fINAL `, ( ��r� ���� 8.8P.C.for this reason DATE '"' e1.S I�'T G C , REPAIR ��.� . � � USE Of �d #j a m w s`�1 �� DEMOL � Date: EXIS7�NG eLDG. D� - FINA � � Signature .. � APPLICANT r —��. 8y ��•- �`}''�'�' ! •2 2$tt 8 - OWNER-BUILDER DECLARATION PRINT The�Anden Gro�.71 99-6864 i; I hereby affirm ihai I am exempf from ihe Coniracior's License � ADDRE55 62g CAV1113 B�-VC�I.. SdII D1I[r1.5��`' ► . � e 2�2 a��� - taw for the following reason(Section 7031.5, Business and �- Professions Code): pRpSE r„ t 2��"'g J � BUiL01NG - I, a5 owner of ihe property, or my employees with AODRES$ wages as iheir sole compensation,will do the work and " fhe sfructure is not infended or offered for wle(Section �OCALITY �C 7 2,,7 A � � 7044,8usiness and Professions Code). nnovWG iet. . � I,as owner of fhe property,am�exclu5�vely confra[fing CONTRAC70R NO. �y � e � � t with licented wmradors�o consffuct iha projed(Sec- qppRE55 rion 7044,Business ond Professions Cade). � a 3 9 Q,;�� . REQt11RED TOTAL SETBACK FROM EXIST. �. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.LINE WIDiH ��_ , � - e ro� I hereby affirm ihat there is a construaion Iending agency for FRONT � �9�����'' the performdnce of the work for which ihis permit is issued RL �°�� /�� � +�2�a,g� (Sec 3097,Civ.C.).(''qntjnpll'F�]_ I.�.�.111015 Nati.onal�� P�oE �, �� . , Lender's Nome B�� & 2�5� CO. of Chieaao r r. ; 231 S. Ia Sal.le St., Chieago, 111. 606�9 p.c.Fee S Pe,mu Fae '���f1 � - Lender`s Address �,. I certify that I have read this application and state that the issoan<e Fee ��i. .5�� k. �. above information is correct.i ogree b comply with all County Investigmion Pee �� ; ordinpnces and Sfate laws relating to building cansiruction, �s" ��1 � �� � Total Fee - � and here y authorize repr sentatives of this County to enter upon above-mentione roperty for inspection purposes. � � -- �- � ].Z,�Z�H3 SEE REVERSE FOR EXPtANAiORY LANGUAGE Signawre of q plicant or Age Date � . ��s �/� �, . � o __ r.� ....---."""--- �7 j � � _.._--�—�`�, � � p � � � ...--- � c T� G} S -9 O� �'l'L� � � O Q . � ��4 Q �} � - � a �n � E� � �y � t � _ 4 � _r" r U R � - � J¢. � � =! `a p -". . � . ,�. 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