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HomeMy WebLinkAbout0770A (4) , „ . , .. -- --... ... --- ----- - .._.__.__.._._._ ..__.. .__.. .---. _. ...�_�. ___ �_. ,,. . WORKERS'COMPENSATION DECLARAiION �'• ' �� .' � � '.'^ � � . " :: . . ' �; :� ,. �: .._ . ... - - s - . . � - - I hereby af6rm ihat 1 have a cerfifimfe of�o�se�,.�o,e�f APPLI.� .�'IO.N.-FOR-BUILDING���PERMIT . �� �,; insure or a ce tificate of Wo�ken'Compensation Insurance � ._..-- - . . . - �' - --- - ..' -. � or a certi ie copy 1 ereo ea ,Lo . . �' �� - . - . . _.. ._..._.. �7a�W�05=279-007tfiom��Natioriwide'"" 1/A COUNTY OF LOS ANGELES i BUIIDING AND SAFETY ,� , ::-� � - - - _ _ _ Q. Certified copy is hereby fu.nished: '.'. FOR APPLICANT TO FILL IN BUItD�NG ` � ADDRE55 503 .7on Court� �-,Cerlified copy is filed with the counf'y building inspeo- -'�-�- BURDING � ��tion.deparlmeril: A�DRE55 503. Jon Court . ,�.; �.,, �.,.� ._� .... ., ... . .....� ��.r,. � __.__ . ...___ � o6re•'7�A�R7 Applicont THF. l�NDEN GROIIP arv 'a d a nv 1 ' iocauTv �'`��`CERTIFICATE OF EXfMPTION FROM�WORKERS"� - �� -� - �-""-- �� -- - NO.OF BLDGS.- � ----- t�nREST. . � - .. . .... � .._ .. ... _-_...- � ` - � � �'COMPENSATION INSURANCE�-�� �' � �� SiZE OF LOi NowoN ior : caoss sr. _Diamond Bar��Blvd. Golden S rin s 1�, (This section need'not ba�compleied if�he-perinit is for ona - -- ASSESSOR ,: .. �-,"�"' ���-� �� '� hundred dollors(EIDO)or less.);... TrtaCT�42$79 --' etoCic - ioT rio. 43 ! MqP BOOK' . '. ' PAGE PARCEL ', , TEL. �P ...,.. ..: ... .. .....�. .:. .. ... .. . ..- OWNER... .. ' ' .NO .: _ ZO E � . . 1 cert fy Ihal m the performante of Ihe work(or which this � �..� . � ' } permit is iisued 13hall not employ any person in any manner . SPEC�nt��--� � �- �• � - �- - � - --- �� � 6. � __� .' AODRE55-P.O:-BOX-33L9_._,.' __' __-___. ... �G1J'17 CONDITIONS . : ... ...._� .. � O so as to become iobject to rhe Workers'Compensalion Lows V �.. „ .. . , . . , . . . � _. ._ .._ � : .,,...., . _. .. . , i, . ___' Cltt_ ..__ ' .___..__..__'_..__ZIP __-. .... _ . . ._ - - -:OC e � ApplfcaN �, . - � ' ARCHITECTO � TEL. . .�. . � � �TICE TO APPUCANT: If after'making this Cerrifi�bta of ENGiNEER �ave�5zan :��. N0.44 -GO� � �.DISiRICT GROUP. TYPE_ _ . _. �.FIRE OCESSEDBY . Exemption;'-�yo� should betome`zubjett'fo-Ihe'Workers' "' --' 1 CONST 'A`7 ; ZONE . . .,;� Compensation provisions�of Ihe lobor Code,yoU mUSt fOf�h- pDDRE55 314 N. F1TSt� Arcadia 9.�.QQ6 � - .f�.--. �-3 -�� �rv-� ���� -� "� 'N wi�h comply wi�h'such provisions or �his�permi� ShOII b0 �-- TEL STATISTICAL QA$SIFICATION � AP7. CONDO. Z deemed revoked:t..',. � .'�.'�, .'. . .. •,•.:� •. ��� CorliknC70e No. � .�d iA. _ _ .. .._. . . . " ---' � - --- _ .. _ UCENSEDCONTRACTORSDECLARATION -....�.• ---- --.-._ - -..... . . .. . ....... .tIC: ...-'----.-.� ��NO. 0 .' OWELL.UNITS , . I hereby aifirm that I am licensed under provisions of Chop�er 9 AODRESS 5 ame aS above No. 510560 ��R�P (commencing with Section 7000)of Division 3 of the Bosiness ond .__.... ._...__. ...... .. --'....... .... _. ... .._l�C.. --'-._.. . : I ; ' �� � _'�-.'-'-. '--�--..... ._..-�•--..._._. Professions Code,.and my license is in.foll force and effetL Citt M55 -� BK `�.� . ' VALIDATION � - .�. , . . �.....� . �,:: � .- . , ' . 50.FT._ NO.OF_' __ . NO.OF._'__......___.CHECK , - , .. � � SIZE STORIES � FAMILIES ONE ticense N�mfier' S10560 � • ��� Clazs B' VALUATION ' � �-...THE+ANDEN GROUP . .7I8/87 _ �exeivrioNOFwoeK--Sin le Famil — NE'�'—� _. .. _. - : _. ___ -- co„f�a�,o� oe,a � S 7,8 0 9 , , , . . .. .. . . .. . . ADO � ❑Iame:emprunderSec. ---- _._GaLage.----41$ SF--..- -------- - -- - . . .._ .._ . . . ._ .. ..,; . .,� _... -. AITER � . ; ' . , _ 8.8P.C.{or thi5�rea5on '____. . REPAIR. Q -.. s.._._.._ . ....;. ..� _ :. . .._0.7'�,Q Fl-. .._ _ ....._. .---.._ .----- ...__. .,. uSE OP � . � 1 '. ..-Dote: E%IS7ING BIDG. DEMOL ❑ _' . ..__.�'• •.o_•.s. . _ , . ">._ ..,.., �--- FIN . - . . .. .Signalure ._._ ....'_ '_""'_"'_ " APRIG4NT TEL ���.'.. ...�_�_�..7�.2.r3._..; OWNER-BUILUER UECLARATION _ _ PRINT THE ANDEN GROUP No. � onre-�2 , . . . ' ' . -.--'.,_,..'-'- � AL � -I hereby offirm that I am exampt from Ihe CoMroctor's license $gII{e gS above�_ � � / � • � �... � ..�.;� '•w for the following reasori-�SecFlon 7031.5, Business and ADDRESS BINAL �.y/ � -�J � I • ^ o� 2'S� ...._'_._.__. .__.. ._'_-//i .Gr/�"� jfessions�ode):. _ .. . ..'. . --' � -�- rae Nr . Y e✓ v � .. ... . � BUILDING , ' O F� ... _ _ . . I, as owner of the p operry, or my employees with nooees5 - -`.\� ._ 7 �''7�' � . . . .... . ._ .. . wages as t'neir sale compensation,will do ihe work ond , , • . � , the st�ucture is not intended or oifered for sale(Section ����TY ' 1 � � " � - �•. 1', --� --70aE,Business and ProfessionsCodeJ.� -�— - - - -- - MovttuG'---. ....-.. . ..._... ....------rE�. --- -._... . ..; _. ___ - ` -_i ---,.-- � _ _. _. ._. _ _ . . � I,es owner of the property,am exdusively controcting fOMRACfOR NO. � ,1���. �r- ' � -❑--wNh�licensed-contmctors to canshuct the pro�ect(Sec- '-.` .__.. .... . . ..._ .. ..__.. .__.. ._._.---.. .... _-.-_.. _._. .._.. _. , � � _ _- .-. .-'- ._...--_.- ..- , lion 7044,Busfness and Prafessions Code). ADDRE55 ' , , ,. ...._ ___"_ .REOUIRED_ YARD NWY' TOTAISETBACKFROM-. XI T. _.. . . ....... . ... _"__ "__._......_ . . . .._. ._...__.; ---�-- CONSTRUCiION IENDING AGENCY-�'---- SEl BnCK PROP.LINE WIDTH� . I hereby offirm Ihot there(s a cons�roc�ion lending agency for ppONi � � • - ' -Ihe performance aFlhe work-(orwhith Ihispermil is issued --.-" -'P.L--.. .- "--- '-'-"' ' - ----.-.----�--' --- ----- . ...------ �� � -�-��-�-- - �-� - '-�-��-��-- : (Set.3097,Civ.C.). . SIDE . ���, i`� , - _._ _ ___ . ___. —__'_.' ._ __ P.t.. ___. ..__. ._._ _ ... . . .._ ..__... . .... . . . . . _ _. Citibank lender's Nama � - --'-" P.0 fee S '-'--'. -' . _.'.. Permir fea---- E)3.75 -. �nnn aet.a , .- ' ��. --- ---- __. -- -- - —— — Lender'sAddress444 $. Flower. T..A. 9D071 10.5� ` -1 tertify_ihaf hove read this opplfmtion ond.stata Ihal.ihe _. ...' -_._.._._---_..__-'. '_ -_-' Issuonce Fae�- -- -. ... . _" .L�MA P/C M--. ......._ ._... .._." . -...t. ... obova inf rion is correct.I agree�o comply with all County mvest�go�ion Fee 74.2 5 o�dina s nd 51o1e lows relating to building.consfrutfion, .__.__ . � -� Toial Fee-�---�- �------ - � IDMP.Perm:N � �- _. . . _ ___'__..._._._ ._ _._. '� and r uthorize represenlatives of this County to enter - upo bo nlioned properfy for inspec la purposes. , A . _...._ .. .. . . __ ..' ' "_ . .. . _..__._. _.._'.___.'. .__'_ ... __ . ._.__ ..__. __ --_ _ .__..__ . _ .___..._. ���/J 8 SEE REVERSE iOR E)(PIANATORY LANGUAGE I � �� �L ' ' __ ._Siqno�e of Applimnt or Agent--... .. .-. . 7e ._ "" ._'' "_._. ' . .. .. .... . _.._.. .. . '__ _ . _ � . '_.�. i _ _... .. ' . . ..._ .__ Q i m T (�= r r m T (/� T N O � U1 T� � _� T ,_.. Z ��I . - 1'o a c° T T � o o � m ., o 0 0� �.a �. Q � � �o -- -- --- -- o o . o ; � c�D i � W � d �o. D � o � n n:W p' 7 .� J :t� .^. m � � � p 0 v� v..N .� : . . 7 �Z x �,� j l�-7 � � 7' � �.� 10 � '0 �(� !;. „ � m o f � w I o 3�- n� o. o � ,� D�.� ° 0 3 0 ' � � '�^ -t i m „°,v' � v 3 n '�: a:': , � �(� .I' � Q O O n ' O'O . '_' fD ' n � � a o a w � �•� , � 3 0 .' � p I J � v7 ', v� . � � �.M . O L'.': � ' :7 _. . , � , . A O l0 �� _'__ �'� , �' i '.� � O . 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