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. � � -- �-
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