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HomeMy WebLinkAbout0771A F ,..� . . . ...' ""__..__...' "_'. .�.._ _ �. . . ._._ ..�_...__..__..........-.__.... ,... .._ ._ �. - ..." ' ...._. ... ' , i.. .. '..._ I,; . . ._ ... .. . ... . . .... ... WORKERS'COMPENSATION DECIARATION . .::�- , . .� , ,. ,.... ._ , . . ,.. ,., .,i . - � -- ._._.._._.__,.. � ��� � - --. _. _ . . I hereby offirm Ihat I have a�cert�f¢ate of consenllo self APPLICATION FOR��..BUILDING� PERMIT��� ��' insuie,or a cerlificote of Worked Compensation Insuronte, ; . __.__ _._._. -- . _ .. .. . _. . . . .. 'or a certified cdpy� ereb Sec:3800'tab.C.) '' ' COUNTY OF LOS ANGELES = BUILDING AND SAFETY � •,. , : 73i�C005-279=0g 6'�'Nat'ionwide ' 1/C ,,_ _ . _ __ .__ Poliry o: . ..,, om��y... ....... _. ._._ ����Certitied copy is hereby fornished.��` '.�.�.,�� � - �� FOR APPLICANT TO FILL IN BUILDING -� , ADDRE55 . SOL JOR Court � Certitied co"p'y'ii filedViilh Ifie counly building�inspec- ��� � BWIDwG � �tion depa�lmenl:���` " � � �� � ' ADDRE55 501 Jan Court � i . ... , ....,,PP.. . . .,.. Dote��' IIHIS�....�.A Iicom.-�THE.-� .,�'i.:,�.0 ..., ' -- .___ . . . . .. ' . . __ _.. ' � � .. ANDEN TROUP arv Di�nond Bar zia 1 6 ; �ocAUTv Diamond Bar; � � �''CERTIFICATE OF EXEh1PTION FROM WORKERS'�` �'� -" � '-`�-'""-" "-�-- " � � -- �Na��BtDGS.� � -�� -. NEAREST. � : __ .._. -'- -....' - ' '-'............ .. . ...... .. " "t'�-•�•`COMPENSATION'INSURANCE�'���- .� � S¢EOFtOT NOWONLOT � CROSSST.DIBIDOItd B8L•BLVd./Golden $ Ylri S ' .,, ...,... (THis'sectian need�naYba completed if�the'permit is�for one �--���� ���� -�-�� ASSESSOR... , �--��� �� --���� ���+���'. hundred dollars(E700)or less J :.: . , -., 7RAQ�FZS79� �---- BLOCK - .. .. lOT NO....��i�i ' µqp gppK ' : �.'. : PAGE� PARCEI:. : , . , — own�ea - � --nio. 967-9541.. U ONE �N+P i I cerf fy.,that m t�e performonce of Ihe wo k�for which this r �. � � • ' ��.} i� perm�t i5 issued I shall not emp�oy any person in any manner � � - � - SPECint- - � �- - -� � --� _- soaslobecamesubject'1olheWorkers Compensattorilaws �--- ADDRESS-P.�.- $OX-3329--- ---- - - --'--�- � -' QOl7 NDITIONS � � • . . ^ �r.� !V � . . .... � . ., . ,.. ,, .. . . __ _____ �e. .�. 7 .� -�� "A �mN . . ,•�. . . ._ _.__._ [JTY._-_ ___ _____"____ZIP'_... __ _< _ _" - -.. . - .. .. . , �K NOTICE TO APPLICANT If'�ofter'making ihii Certificale af ARCHITER OR ' TEL „DISTRICT GROUP�TYPE._- ._ � FlRE. PROCESSED BY. _�',� Exempllon,�You"should 6ecOhie��sub�ecl'fo'the�Workeri ---� ENGiNEER - � NO. _ ' � " ��T ' � � Compensation provisians of the La6or Code;:yoa mVsf fodh- qDDRE55 3T4�N. First, Arcadia 91��6 .. �.._.... .�.\3 __ _� �� _. _. _ . � � with comply;with:such prOvisions or this�.permif shall be -- TEL. STATISTICAL IflCATION � APT. CON�O.�� '��2 deemed revokedr� . ;. �, ,�.�,.;• .. -- •- CONiRACTOR NO. � , ,. , ...� . . "'_ '_'_'" . .__ �._._.__ ._.�_.. . . . �ICENSEDCONTRACTORSDECLARATION �- ,-+•. --�� -----� -- ---�-----�- -� � -�-- L�C. - �- - - C7a55N0. ' DwEtl.UN�TS � 1 hereby alfirm thot I om licensed under provisions of Chopter9 noDRE55 Same 3S above No. 510560 �R�P ;:� ([ommencing with Settion 7000)of Division 3 of the Business and ___ .. _......_ _._...... _.._..___. ._._ IIC.� �- �--�--��- �. . . . . Pro�essions Code,and my I;cense is in full force and effect. Cltt ' QA55� � -�� ��BK.�-- �. -- �- i -'" VALIDATION-�� -- . ..�,� . . ,. �� .. ,,.... ,., , , ,510560„�- • � • g �].fT. NO.OF NO,OP CHECK � Ucenie�Number --�L¢.Class ""' S¢E � � �STOe�ES � PnM�l�ES �� � ONE-�� VALUATION � ' i � � - .-,THE ANDEN GROUP 7IgI87 .. --- nescaivriorioFwoaK----Sin le Famil - - � D - - - � Connocfor Oa(e ' _ ' � - N ❑1 am ezempt onder Set , .. . ..• . ....- _.___ ___ _ ._...-- --- . . - _. �_ .. .. ADD 7�809 � . . . . . ....❑ � , I '� - . � ..," SLAB ONLY ALTER � . • . ...__. - ---- - - _ _ _ B.BP.C.forthisreoson S-- -- -� USE OF RE7AIR..❑ i � � �G rI Z� A -_..� _'.. ---�-� - --- - , o � "" " �atef' EXiSTING BLDG. DEMOL � _ � � �'� � �� APP�IG4NT TEL . • • • . __.. Signature '- - � -----. .. _. _ :�.. . I FINAL �, / �_ � `. .'rF� . OWNER-BUILDER DECV+RATION _ PRiNT Na' ' _..DATE-�- � - --- — � �-J . .']Q,�2�j--� �� -1 hereby affirm tha�!om e*empt from�he Comrac�or's ltcense �� � �. � „ . . . " for the following'ieoson(Sec��on 7031.5,Business and nooness SainO SS 3bOv0 . � flNAI � � ' ` �� _ ._.�.._.___---�. ..._.. � .. ..., _ ._ • �essions Code): _ _ PkE N ey �_ '..° •?�.2 Jr ��. 1,as owner of�he property or my employees with ADDRESS ' -. -. . :, '�,� -: O S� �I�8 I wages as IFeir sole compensalian,will�do the work and � � -- - � � - � � � �:�� , � �-� -�� � -� LOCAUiV , .....- . �� ' � .' . _ the srruUvre is no�Intended or oifered for saie(Section + - ; � � " � �7044;Businessand Professions Code).— -� -" �"�- MOVING'--.-..__ ..'. -. . -� - --"....--TEL:.-. -- -. - .. - ..c�. . . � �. . � : . .. - _. � : � CONTRACTOR NO. " I,os owner of the property,am ezdusively conlracfing ' , 4, �-'1 •`'�',':= �' , . ❑--wirh�licensed convactorsro consrrud tha project(Seo- ---�-- --��--�--- .. _.. ..-_.._.... ----.-_......----- ._.. ...._.__. .,- _.... ...._ ._[.'-�.. �.� . . . .: . .. ....:-._.. _ ._......... .---' tion 7044,Business and Professions Code). ADDaE55 � -'_ _ . .."___ 'REQUIRED .-TOTA�SETBACK FROM.. %I _._.._" '-__'"' ' "_... ._..: ....I_ . .. .__'.''_' -�" �--CONSTRUCTION LENDING-AGENCY---�"�-- - SEi enCK-- "YAttD HWY� PROP.IINE WioiN �� I here6y offirm thal there is a consrruction lendin9 agency for FRONi . '" '' -�hepe./ormance of the work for which lhis permit is issued .-_-. -v.Lr---. . .-�- ---�-- --'. . -. -._.. � --- -.-- .- -.--_ ._ - .. ... �_..._. . _ .._. (Se[.3097,Civ.C.). SiDE � � � ' .. P.L �. .�..... ' ----.. . ._.__. ._Citibanit-.:--- --- _----- --- __. . _ --- . .. _. . ... . . _....._; lender's Name � 63.75 - �r.wa�r.x _ ' , _ " '444 S: Flower__L':A. 90071-_' v.c.Fee s - - e�.m��F« _ . Lender's Address � � . - � _I cerfify�hat.l.have.read this applitotion and.sta�e.that the ..._. -. �-�-- --. . . _--.-.._._ �aa�once F�e� �].O.5 � � � �� -� - � .._"'_" LDMA P/C R'' "....__ ._.. . .. . ,-._...._ abova iniormoYon is correcf.1 aqrea fo comply wifh oll County Investigotion Fea � - � � ordinances Stata laws relatin lo boildin constroction, � � '�� ��� . 9 9 '.�.' _.____'_'__ ._____'._._ . To�olFec_._']Q.� .. . ._ -IDMA�Perm.-N_'._..__. .._ . and here horize representatives af Ihis County to eMer �-� � - - � �- � upon t tioned property for inspettion purposes. � . _� _ .___ ._... _ . . . __._ ..__'.. . -'-- -_......_ . _. . _. .-'--. . --._-. . __. ._ .. _._ . _ ... . .._. . _. SEE REVERSE FOR EXPIANATORY IANGUAGE ---:SignomreofApplicanforA9enr-.. ......��_. .. . .. _ . . . '_ .. _ .. .. ._..__ Q i 1 _.. ._ .._._' . 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