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HomeMy WebLinkAbout0772A (4) <. . . ___ _ _ __ _. _.,, . _ _ .._._- --- . __.. ... _ _ _ _ - -_ ---- WORKERS'�COMPENSATION�ECLARATtON '•%" �. ` '' - • '-� -. �•' , ' � .._ ' }i ,., ....,. .. . . . . ,. , . ..., � _ ._._.__ . . .. . . . , . _ I hereby o{�.m ihot I,ha e o certff�care of consent ro self APPLICAT'ION FOR:BUILDING PERMIT insure,or a certifimte oF Workers'Compensation Inwrance, � . _,. .. ... __ . _.._. . ...,. ,�: - -- �-- � :.._ Pr a certifled cbpy'thereof(Sec.3600.'109.C.J. . .- - _.. .--. _. . ...._._.. �'e��,3I�005-279-0(�].o����jlationwide', ' ' 1/A COUNTY OF LOS ANGELES , BUILDINGAND SAFETY .••�, � _ . .. _ _ _. _ � - � CertiFied copy is hereby fumished.:• ,�..•� . •. , _ FOR APPLICANT TO FILL IN eu��owG. , � , ,. . ADDRESS � JOiI 011TI � OCertified copy�ii filed with Ihe Eounly b'uilding-inzpeo- -'""�"- BUILDiNG �� �tiondepa�lmenl.���- � � �� �• � � � � ADDRESS 504 Jon Court , - ' � �, _ _ -.--. D6te��•�JIBIB� 'Appli�ant��THE�ANDEN GROUP � cirr Diamond Bar zia 91765 � �oauiTr Diamond Bar�; � ' �� �'CERTIFICATE OF EXEMPTION FROM WORKERS' � - SIZE OF LOT NOW ON LOT � � CROSS ST.D�BlIIOIld B 1I;B ZVd. � _ ._.. . ._ __ ..'_ -_ -_ND.OF BLDGS.-__.. NEAREST. ;. .. . _......_.__. __..._..:_ ._ ' �-� ��� �-��COMPENSATION INSURANCE'��"-"� ' � �/Golden S rin S (This sec�ion.rieed noe be�completed if the-permit is for one .-...- - -..-.. --. -..-----.. .--- -- - - n55E5SOR.... . :._...� -' --- " .:.-'.� ' . hundred dollars($100)or less.)., ... � , ., � TRAQ4ZS7 J. BLOCK LOT NO. � �+6 �,�qp gpplC-" '� GA�GE� PARCEL � �... . , . � � .,.�., . . �. .,..... ._.. .. .. .. TEL. . � USE �NE NV I terhfy.lhot�in the�perfo�m6nte of the work(or which�this OWNER- NO." - � � p�p � 't!' � �, permd is issued,l shall nol employ ony person in any manner ' -- SVECin4� ��-�+- � ^�--- � � � ��� � - _ � SO as lo be[ome iubje[i to fhe Woikers'Compensation Laws. � ' ' ADDRESS-�P.�.��Box-3329��- ---�� �� -- �-�� �-� - gU0 v CONDITIONS . -� . 'V �. .. . .... .. � � '' ...�., _ ... ._'__ CIN.._... ' ..__"._______ .._ZIP_.._'_...__ _ '_.' . __' _ .._ . � ..: e i .:�qPPlimnl, : . . . _. _. . . . O ARCHITECT OR TEL. rvOTICE TO'APPLICANT: If oftei'�moking this Certifitote of ENGWEER Dave � zan i N DISTRICT. _GROUP TYPE _ ;FIRE_ _ ROCESSED BY. &emp�ion,'ryou•shovid 6ecome�sob�ecf-lo�Ihe�Worke�s' -'- - : / CONSTy. h, + ZOfl•IF,� . G Compensation�provisians of the Lobor Code,.yov mus�fdrth- � A�DREu • � - 1�O �3 �� '`�- !-�V _G"-.- �-- �_ _�pW, with comply�wilh such•provisions or Ihis permil shall be �-�� - deemed revoked:'_.• .�. ' . � � TE�• STATISTICAI CLA$$IFICATION ; APT. CON�O: �- ��Z . -. , • :•,�, " .�...' . COMRARORTHF AND G NO. � _ .. .. ._'. . _ __. . _. .._ _ ._' _ �: LICENSEDCONTRACTORSDECLARATION ��. .�-•, ..-... . -_.. ._. __ ..._. ..._...._..., _. _ _._��� _. ...._ ..._.. M53N0. DWELL:UNITS i hereby affirm that I am licensed under provisions of Chopler 9 ADDRESS NO. • (commencing with Section 7000)oi Division 3 of the 8usinesspnd _.._ -.--.--___._. _._...__ ......_.---_-..... LtC.-.--. .: �R nMP ; �.. . .. � . -- Professions Code,ond my�icense is in full force and effect. CiTY CLA55 B � '-'��� BK.�--���:' �;�-'�' ��' `� �---��-VAIIDATION" ' " � i - . . SLOSE)O - .. � . ... SQ.FT. NO.OF NO,OF . _ .._CHECK_ . ., . . Conrractor THE ANDEN'GROUP pa eI055 B _ $RE � �$TORIE$ FAMILIES� � ONE . �� ...VALUATION_ -_ .._.. . ... .. . ;^O772A- - I am exem t under Sec. � 7/$/87 DESCRIPTION OF WORK-- 1- - ]_ �-�-- N�-�� � . Ucense Numb�er L c C ADD � s � 7�$�9 : : ��a .'.. ,�. � _..---- --- Gara e-.—..._418.SF-•--- -- ----- -- - � ' � � . . ... �� P ... . .,.. .. . . ALTER .. , I • .,': . .-- - - . SLAB ONLY � s ' ° I.•.'7 4 2 5 B.BP.C.for this reason . _... � REPAIR-. - "" � - -�-'--- ' -- �"--. .. ....__._ .__._...___..._.:____.__.Da}e:_._..�_ . � USEOF DEMIX ❑ , ' _ .. :.__..__ n e •,7n,�.s.c=i_� E%ISTING BLDG. . .., .,;. .,�. ___ . . �, _�..-Sign6fure ---._ ._._ ...__. '.'_..... ._._.. , . APPIICANT 7EL. iINAI /�/ , OWNER-BUILDER DECLARATION PRINT THE ANDEN GRaUP NO. �- / � O�� 7"H 7 _ � y ' ezempHromtheContmdor'sLicense -. . - - . . - . . ...DATE---- /. G�-.�-.. " " .--- --.. .. . ADDRESS SalSt� aS above .. � - - . . 1 I,as owner af'eason'(Settian 7031.5, Business and FlNA� " ' � �i ssioniCodeallam ..... - ... . ... . ...... .. _ .. reeSeNr �`-Ey-�-� i�� - � --� .�. w for the following r , �•, � BUILDING , '' � ; he prope�ty, or my employees wi�h ADDRE55 • , ��, wages as the�r sole compensmlon,w�ll do the work and - ����� ��- � � � ' - - � - � , the structure is not in�ended or offered for sale(Sec�ton ����TY , . � , � � " � .-.... ..7044.Busfness and Prafessions Codaj.... ."" --� �-� � CONTRACfOR � �� _ N�. �� ��� � ..i ;.,� �.`.�. .'' �:... ._ . . .. _ ._ __' . '.'._ _ . . _ _ � I,as owner of the property,am exclusively contmcting � - � "�� � � ' -with licensed contracrorz to conztruct tha project��Sec- - . .. - .._.._ . ... ------- ._....-'-- -.'--'-... .. .___._-.__-_.-_ -�.. ._ .. - ;,� - . --'_..__-._.._ - fion 7044,B�siness and Proiessions CodeJ. ADDRE55 , � _..._.._. __. .. .__ REOUIRED._ .TOTAL SETBACK FR M. I .___ . _ -"�"-" CONSTRUCTION LENDING�AGENCY --""�� SET BACK �YaRD HWY- � PROP.IINE Wioiti � �� -� - � ����- - � �� � ���� ` �� � � - I hereby affirm that there is a tonsrruction lending agency for fRONT , ' ' '' ` �� I -Ihe perlormance ol the�work(or which this permit irissued -' ��P.l.�- � -- �- �-'--� - --...---...- ' -- - - - -- - '� ---- ----- -..r_---- -�.- -• '---„ " - (Sec.3097.Civ.C.). S�oE . � � ��I ._ ..__. ....__.. . ..__ ,._ . ._.. ... ... ___._... ... ._ P.l. ._ _ � _ ....._._. '__... . .... ._ .��_'. ._ _- _.._______ .__.-__ ''� , Lender'sName Citibank � LDMA Ref.M �:. '� � . _...._ _ ... .. _. . ._._ _ ...... P.C.-FeeS.. . . .... _.. Pe.mi�Fee 63�.7rJ .'_ _.. . . .._ _ _ Lender'sAddress 4l+1+ S. R�o_Wgr� i•-A- 90D71 � .1 certify thot I hove read this applimtion and s�ata that.tha ._... .._ .._. . .. . ._. --hsuance Fee-- - � � �DMH P/C M-._.. ,- . ' . � � . . -�. - -._.... . . _ ._ . .- - above inform ' n is cortecf.I agree to comply wilh oll Caunly � �nvesuga�ion Fee �� �' ' .,ordinance Stale laws reloting,to building COnsttuCtiOn, _. ..._ --� Torol Fee-�-� -- � -�- - ._'_.'.'._ '_."_." ..' _ " LDMA Perm:N...._._.._'._r'.. . .'_, � . and her y ulhorize represeMatives of this County to enter � i -� �-� �j opon e v entioned properfy for Inspectlon urposes. � � � --. . . -.-- . -. . /� ' - . ..... .. . . . . . . . . . .. . . _._... - ----- . _. . _... _ .. .1 __ . . ...... . _ . .._ .. ..._ jj SEE REVERSE FOR E%PLANATORY LANGUAGE � i .._.-_.Signarure of Applicant or Agent . _ . . �e ... _._. ..._ ..... . ... . . ' "._.._ .'' . _ ..'"' �'_ .'_' ' '....' '_'. ..._`_ _ .._ _..._ . . ._. _._ __ .. _OQ� o �o • f_ _ . . � - � . ,� �. �o' '`1,, .` � ..� m g ',� ,.. N T�-� O, a Q S n �.,.. �.` ' r (�b j��(a9 p�, '� V O '� •p.�'.'. \ . D -o O O � t+.�r �p �O O b s;, . 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