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HomeMy WebLinkAbout0731A (4) ., , ., . . , _ ..__ ..__._. _. _.�___ ._ ._ _ . . . .___ WORKERS'COMPENSATION DECIARATION .-�.. . '�'. �,�^ .- ��......�-_ -..��.....—^- ..� -'--.. T'"----- - . . . .. . .- . �� , . ..__ . � -J. � __ . ' � I hereby�affrm thol I have a Cerlificale af�o�=e�,�o,e�F � -- APPLIC�ATION��_�FOR��BUILDING PERMIT-� � insu�e,or a tenificofe of Worke�s'Compensa�ion Insuronce, -__ _ .._... . .. __. _. .. ... � .. ' or d certi le mpy t ereo (Seo 3800,'LoB.C.)...'• .`.. . . .-.. . . ... .. . _ ..... _ rol��o 005-27.9-OQo�Pa�j�ationwide' '� 3/C COUNTY OF LOS ANGELES BUILDING AND 3AFETY � " � � Certiiied copy idhereby(urnished: '�r:..-...�. FOR APPLICANT TO FILL IN bUILDING � 1 . . ADDRESS 50 Jon Court ❑ Certilied copy is liled�wilh Ihe county 6uilding inspeo- ' �- BUIIDING , tiondeporfinent,�� ADDRE55 507 Jon Court , 7/8/87: ` THE ANDEN GROIIP -- -- Diamond Bar ---—- - .-- � � ' Date Appliwnt arr zir 91765 ��,�iTY Diamond Bar ' -� CERTIFICATE OF EXENIPTION FROM WORKERS'- - � $IZE OF lOT � NOW ON`IOTs CROSSSST. D18IDOIId B3L.•B ' __ . . ...__ ___ _.__... . _ _.... _'-'. ... _ ...-_--."__... ; � • � ��'COMPENSATIONINSURANCE �- � � I.Vd./Golden S rin S � . ,... , . _ . � ASSESSOR,. . '____... .... .,..-. (TBis�section need not be�compteled if�he'permil is for one ---� �-- �- ------- - - �-�- - - , �, � :`.� ' hundred dollars(SI00)ar less.) _,�,,,,,,,,,,,, ,, , TRACT�#ZS7I.�.�-- BLOCK .�.-�- LOTNO. �1Z ' MAPBOOIC � . . • . PAGE: 7ARCEL ' . � TEI. USE ZONE 1�.P I cerfify thoi in�he performance�ofihe`work for whkh th�s � o`�/NER 'THE-ANDEN GROIIP `---'No.96�-9$41- �,�p � - ,} permil Is issued,I shall nol employ any person in any manner ��--�-�-- 57ECinl ---�� ��� � � � �� � ��-- - - O. - . . . . . - . - _ . -----...._-'---._.._._ . . so'as to be[ome subject to ihe Woikers'Compensolion Lows. � ADDRE55 � CON�ITIONS ' ��Q .... . . ... , ... ... .. ... ,, . . ....� V �e �.A . �..'�APPLcanT .,,.,. .. ., ,. -.. .. CITY_. . ' _ _.... .. __. ZIP_' _ '. - -...__.__'_ _ __. . .. � _. .-.' . ......, �'� ARCHITECT TEL. �O . TICETO�APPLICAM: I4,�af(er makmg thii�Certificafe o( � � DISTRICf._. GROUP TYPE, _. FIRE... _PRpCESSEDBY__ eN�iNcea ave Szan AIA No.445-40 ' - �- Eaemption;'you�shou�d betome�su6�ecl���to�the-Workers' ` �Q C0�^/ AJ1 � 1 �V Compensotion�provisions of the lobor Goda,yov�musf forfh- A�DRESS 314 N. F1YS[. Arcadia 91]22 - - 1 O- „� .y-�/' . ��l��e � with�mrhply wilh such provisions or Ihis.permit shall be .. - �- i tn TEI. , STATISTICp.I�L4551FICATION . � APT. CONDO: �. +�Z deemed.revoked...!.1 .'' : ,. , ..•,,.,<� ,. .:'., ' COMRACTOR NO. ' - �� � ..:- IICENSED CONTRACTORS DECI.ARATION•..,- .•�. . __ ...._. ,_" ....__. . .. _. ... -�LIG. .. .. .._... . aASS NO. � OWEII.UNITS � �._ ....�-... 1 hereby affirm ihat 1 am licensed under provisions oi Chopter 9 nDDRE55 Same HS above No510560 . � (commenting with Section 7000)of Division 3 of Ihe Business and .. .. .... ... .._ ._....... ......... .._. .... LIC...... ... . ��R MAP ; i . . . :. . ; Prolessions Code,and my license is in full force ond effeU. Ctiv cw55 ---�BK;�-- � - - -� ' " VALIDATION"-�-"-� . . . „ ...., . . ..: - • '. � � ' SO.FT. NO.OF NO;OF_ CHECK � � '� - � 'S�-OSGO '�' '•" � ^� ' '�B�-��� -� SIZE� - -� S70RIES � � FAMIUES � ��� ONE��� I� �� Lcense�Number - l¢ Class � , . � . ... . . . .... . . . .: -�,.:.. W TI N ' . . T � _..VA A O .. -- .___ - - _ - --._ . Coro.acror`HE'ANDEN GROUP` Date. �I HI H7 ; - DESCRIPTION OF WORK • N� = 7�2 8 0, �.- � ... . . . . , • ADD ' ❑1 am ezempt under Sec. -..- ._Gflrfl$0.-__!y(2 SF--- - - - . ❑ .`Q'��j A � _ . , _ . Al7FR , : . � . , .,. . ... ....,� : - : . � B.BP.C.forthisfeosOn . � REPAIR_Q .. s_. . _._ _.___,_'__-__ .__._.'_.._ ...�.�_.i.�.�.� '...... . _ . _. ._.._..__..._. .... �010:'_"- ...; .. . USEOF �EMOL ❑ - ' � ' -�.... ExISTiNGBIDG. -.__'_'._'_. _. . . . ,. � ._._. � a . ._..-Signafore �._ ..._-_ .'_-_�... . . _.__. . .. APPLICANT TEL FINAL ���y � I . _____•_ _ . . . PRINT) THE ANDEN GROUP rvo. 6 OWNER-BUILDERDECIARATION DATE'--� �. -r�i3--�� -'-"�...--"-�'a-•']-[(;�Fj�._�� . . _ _... .. _ -!hereby affirm thaf I am eaempt from the Contmttor's Litense . �- - ,h. � � ��' w(or ihe following.reason(Sectidn 7031.5,Business and ADoee55 $2if10 3S 3bOV0 FINAL � ` ��' . • .,_.__...__... �� __ �. .Og� � -87 �- .�(e35i0n5COde�•...... . ._�'.. . _ ..'__' PRE NT . - 6Y f . . . . , i BUILDING I, as owner of the property, or my employees with ADDRE55 ���� 1 -wageioitheirsoleEompensation,willdothework-and �-: --- - . �- � !- �-- - - �ha structure is no�in�ended or oifered for sale(SeUion ��`��TY ' � - . ,.._._. .. . . ... _ - � '-7044,Businessand Prafesslons Code):---- ---- --'�� MOVitaG-- ' ' -'�- """ -' TEt.- • � - --- --��-� CONTRA[TOR NO. ' ' I,as owner of the properly,om ezclusively tontracting _1 ,i (� ..` �.�\`��, 'a'-witklicensed mntmctorz to construct the pro�ed(Sea -�-- . ..___. . . . ...' _' "_ . .. . . ..._.,. .. _ . . . .\ � . . . .,� . . ._. _ .' _-.-" . lion 7044,Business and ProTessions Code). AD�RE55 ' ; � : � ..,..� .-..._-. ..._.CONSTRUCTIONLENDINGAGENCY... ....- - - SE�BnCK � YARD HWY TOTAPROP.iiNEFkOM Wio7H ____..._._. _. __--` --_ -_'_ -- .--.---.,-._.._. .. __-.___-.�-. I hereby offirm thot�hera is o tonsvuclion lending ogency for faONT � ��� - � . � -the performance of the work/o�which this permil is issued .._... .P.i.- - -._.... ._ _... .... ----.-.-..-.-'---...... . . . . .. . ........._.._..---_ . . .,_.._.._- --- : . . _ ._._..._._i ($ec.3097,Civ.C.J. � SIDE , � ' � -------...._.._. _- Citibank-- --....__..._._. ._..... ___. . a.i. � ... ... _ - Lender's Name _..-..- - - -... _.-_.__.._.. _. .. . . -' - 444 S. Flower L.A. 90071` - P.C.FeeS-. - . .- -- PermirFee ---63.�7�J -- LDMAReF.M .� ' � '.���i Lender's Address � � � i _.I certif thof.l hava read-Ihis a lication and.sta�e thaf the � 1�.5� : ; � � � . . . � Y PP .- - _. ...__.. ... _ ..__'--. ._ -- IssuanroFee_..-- _'_'_--..._.._ IDMAP/CM._. ..._ ... ..- - ' ._. .. � ._�_-"�. � above iniorm n is correct.I agree to comply wilh all County Invesiiga�ion Fee '� _ordinance n Siata laws rela�ing to boilding construction, ioral Fee - � � � ����-'-=-' .. '.._._... .._. _ . 74.ZJr .._ IDMAPerm..q..."' .. .._. .. .. and her y ihorize representatives of ihis Coumy to eMer - �� � � , - � - �. upon t ve ' ned propery for Inspecrion pu.poses. - � _._ .. ..--�� --�- -- .. .__... .._ _ .. . .-- --. - _ . . . . . . . .. . , . . __. . ..--- . _ ... .. _ _ .. . _. _ .__.. _..--- ._-. � SEE REVERSE FOR EXPLANATORY LANGVAGE I� � ._..._Signafureo ApplicantorAgenf-.. . .'_' _ �e.._ ._. ..... .". "" '_._... . . ..."' '".. . ._._ ..._' " '-. . _ ....' 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