HomeMy WebLinkAbout1524A 1525A (15) WORKERS'COMPENSATION DECJARATtON � - ^
I haroby offirm that I hova c�a,f;f,�a,e��o�,��,�o se�, r qpp��CAT10N FOR BUILDING PERMIT s
insure,or a certlficate of Workers'Compenaolion Insurance, �tr� B
0�a cer�ified copy thereof(Sec.3800,La6.C.) �� ✓
83-CK-956�-1Q4-CPA AE.TNA COUNTY OP LOS ANGELES BUt1D{NG AND SAFETY
P�olicy No. ompony �.
Certifiad copy is hereby ivrniaF�ed. FOR APPLICAN7 TO FILL IN A�DRE55 24 2 3 7 S EAG RE EN DR. I
❑ Certified copy is filed with fhe county 6uilding inspec- gUILDING
tiondepartmenl. ADDRE55 24237 SEAGREEN DR. �ocP,um DIAMOND BAR
1 23/84 TH.E ANDEN GR.OUP NEAREST
Date I !_ . . Applicant QTY ZIV CROSS ST.
CERTIFICATE Of EXEMPTION FROM WORKERS' NO.OF BlDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON lOT MAP BOOK PAGE PARCEL
(This section need no�be completed if the permir is for one u5E ZONE M.4P
hundred dollars(S1W)or leu.) TRACf 6lOCK LOT NO. NO. ��'��
TEL SPECIAI
I certiiy tFat in rhe performance of tha work for which this OwNER THE ANDEN �'i 11 No —9541 coNorc�oNs �
permit is isaued,I shall not employ any person in ony monner DISTRICf GROUP TYPE FIRE r¢OCESSEo er 0
AD�RE55 CONST� ZO U
w as to become w6ject to rhe Workers Compensorion Laws. . !O �j (� � �
arv COVINA nP. 91724 �
Date Appli[apt . . STATISTIG4LC1q551FIUilON APf. CON00. O
ARCHRECf OR- '..TEI,
NOTI�E T6 APPLICANT: If,-pfter�making this Ceffificqte�of E -1NEER. .�..D � _ � � '�� V
( xemprion, you should become subject ro rhe Workers ���� �� �LL•LNtis,_ w
.:ompenaation provisionn of the I.vbor Code,you must farrh• y
aooaess 314 N, fiIRST AVE. AR bIA sEweRrour
wifh comply with wch provitions 6r this parmit ahall ba � - - � � 2
deemed reroked. cOrviRACfOR T H E A N D E N G R 0 U o9 6 7-9 5 41 BK� Pc, vnuoarioN -
UCENSED GONTRACTORS DECIARATION � �ic.
I hereby affirm thof l am licansed under provisions of Chapter 9 ADDRESS N0. VAWATlON
(commencing with Section 700p)of Division 3 of Ihe Business and L�c. 6 6�9�Q
Professions Code,and my licanse ia in fult force and effect. Ciiv C�V I N ci.45S B E �
� .Ff. NO.OF NO.OF CHEp(
Litanae Number �7 7 S R(1 �i�,C�n.0 R 51 Q STORIES .], fAM1UES 1 ONE
�i ��P '
Comroctw THF. a,N�F.AI [;R(]61.8, 1�23rAd � o woaK � a
❑Iamexemptu�+der5ac. OF SINGLE FAMILY HOMES �
8.8P.0 fw thia repaon E ARR � DA E � 1� � �' `}' z 1 5 2 4 A I
Date: E%ISTING BLDG. DEMOL Q e��S�„_,_ �. . . .2� I
Signafure . APPLICANT TE`. ��,�-954 I •2 2 a 4 8
OWNER-BUIL�ERDECLARATION ��Ni THE ANDEN GROUP NO.
I hare6y affirm�hof I om exempt from the Contmcfor's Liconse S
Low for fhe following reason�Sec�ion 7031.5,Business and ADDRESS j {�1� Jl[t C V I N A C •'2 2��.4 Ci c�
Wofeislons Code): PRESE
.. n BUIIDING �2 1 3-8 4
f J I, as owner of Ihe property, o�my employees wifh ADDRESS
� woges as their sala wmpensntion,will do Iha work and �
� the structure is not imanded or offered for sole(Section ���m '
704A,Business and Profassions Code�. MpViNG 7EL. �
� I,as owner of ihe properry,am exciusively conmacring N7RnGTOR No. �t S 2 5 A
with licensed contracton�o constroa the projeU(Sec- AppREu
tian 7041,Business and Professions Code). ��� � ��,
REQUIRED TOSAL SETBACK FROM EXISt.
CONSTRUCT�ON LENDING AGENCY SET&4CK w'�'R� H� PROP.LIN W1DTH
I hereby affirm Ihot there is a construction lending agency for FRONT ,`
� I •39Q50
ihe performance of the work fw which ihi:permit is issued p.L. � �Y
jsa�.sov�,e��.c.�. P oe s� • •3 9 4,5 Q�
.v/t�
m lenders Name ,/ � 0 2 1 3-8 4
$ P.C.Fee S •7 Permit Fee ��
Lander's Addraas `�
�' I tertify Ihal I have reod this appliwtion nnd aTate fhot the �ys��Ce p� O•„�(/
� above infwmotion is correct.I agree to wmply with oll Counry Invsatigation Fea '1
ordinaneea and Sto lawa�reloting to building wnatrvcfion, Towl Fee .$9� ✓1�/
T1 and areby authori representofivea of fhis Counfy fo enter
� �he abova-m ed properry 4or inspection purposea. �� � �
� �� Z� SK IiFYFASF FOR EX�UHATORY LANGUAGE
j T Sipn na ApPlico r Agenl Dote Q9�
r--•. �.,.
w^„L Y.s. �n 0� ?�.,"�, L'D^ Cl .l G 4� 1. • �n C,Q 4� '^ .
'(? Y..t,' 6 x x t+ �,�Z�C�^.1 . C �f '^'� C .,�}.•M C.. � ��i.�Y U w S
�r� '�'•'� •+ mCj"w iv�'�o 3 °o � a`�•� o � ° fn,N $ N � _
� �O � �` d�„±'d.�wM wh �i V ti1�C`:�n"v C�" � C 0 V 4 ?' C ,,, � . ' . •
c w'� o '4' �: � a°�"c ..:` T � e� "'�'� N ��'^ t. . �, u � .�,`� .. �j
o u x �� 0 3�^�, .e s. o c��"
Z U N c a�b ° �ti''�, � C tl 4.d a .�, �`4 c.`�2s^ � � a.v � � � �
. O s � ° � �;o a� ,-�»''��,o � e � � m a �w h � � '_� r.�c I fi y. � ' � . - . .
� � ° ��°'�' .,; � a�h.r� E-o�° c ��,���'� ;�c . � �:. `.`.�� I 3 :� .
o p " � � .c & r Q w. °' " „�.U �.,�.'h v^�. "; i :,: X � O "ti:
. d� � t' r:.��: � c-v � c;;: 0 3 ` y r•'�'• - -;'•i. E �:'ci y:� �
a, �.: '�` � � � ', ti c.�_ .i; �• U c o e.� ".'r
�' £ c�s::.' ^c��.y� c.` ^ ^ o`d'z �� � c ; e `" . �: �;`�� r.,^,: I
a � '3 ,�• '� � 'o � c�.� i.�`,�.�.i�'�� Q � v��.� �' i; s' t` c p:EY � �
�: �' � .. g .t c. o , 2 ` ; � , c
^: �° `. i. .` L R v�": . �;ti � �T � C a � � � � u-� I �
� r'o i �"�•��„j M r r �: - ?' [LL y ri`',� C � � S �' �0. � �L I � I i I I
t � C s 4� �` W k."' ._ � � C i
...I , L � , (j 1 0 J f ' I
�� " ` : y Z q.F M � �3 y � 4 c ^ " ` o' F..�..` � "! U" .L'.. I � ' ' �
. � • �, ... .- � - c.� {. .
C .. ~'y � c: y� -�C' s_ 4. �� C` .O ..'C � � Gi t ;: � , ! �
�r 9: .. .. ` P
y • : c V s. ; t' .. <. , . 1� I I
. �� � L ��^
� * 3 " � a .e �� t � , co '- - : ° � s � $ - a ° ; ` G P I � �
� � �; � c . _ r � t. �.� � � � . � , I
(^, � c � r �� ^-1 C �, '� O . v C '"t :; c o - '�;y; . E
, f` N ^C„ GG � � C_'°C C.v � � � _ ^ *" hC ti ��� ^� �++C ` � . I � : ' . I
N C .r •:, i,��� lj h � b i• q, '.�-� �� " �' � � . �^� , ;. I
• � t�i ``1 c,i. y �; 1 Y � a ; z L � c' r, a '� s�. . " c � a ��--' :� �'.. I_ ii � � I I � I I
a" '. � « � !�'"V .. •s � 3-r .�� �"� .� ` � � ���i `. ° o � .
f ' �
� � I .
E �
I s
' , i !
i1
� � : �� �
�
� �.�
» .
I' ,
� i
� ' _ I ;
� .
v �
4'f �
� � . . � ., I i �.�
% �
�
.. I I
_ ' ' I
. � � � _ I��� i' '
.
I .
.
�,
, ,
' �-" '_- ___ -_" __ "_ _... "_ .'�'_"'_" .. ' ....
'_ 1� '_� _'i_�_i_ '_"..._
7 . �� b t ( �
O ' > �
d > >
� � O m
< � C C
�t
�� y
.� O M
0 �
�a � a ;
' 0 3� ,
� o - M �.�'� 3 i
Q � `c o e � � {
U i '�. � Z i
� � ` – � i �
�� � � � ,::-- — --�— '— ---
« ' � . ' � �� i E
o. o k: � �i �� '
•.
� z —�-------t._.!. .._..--- ..�:... -�-- ---- --— -- ` � -�� .
. J i :r, i I �' � � �i % {
� � � I � � � _.__.J'_— �-- � —
i �i � i � i: � j�
,. �• � y ; I I
I N O f
CI � � N G' 0 ?. 0 � � { m a � p I-O I
a ' � : o F a I ��i o o a� � � ,� I �- � 'o ..o� l
i � c-. `o £: i• a c Q o c r �J� r > � ° i . � -L � ° p.
4 e.. ci. _ I. c e� i ;, , I � c. o � Ea LL
4; '- u = �` �u c� t3 f' j I �, c � 3. ��
It � � ci. � `-' a^ � ^ s_ . :>. c�= ?`N X Z c
{ U L � C i -G �_ Q, � � v � � 01 : I� �� i p O ro � � 0 C W y� I O
' a o � o o � c � o � o ;o m D � E� y J- o 0 0�
H zp —I '. � 2_ i� l`J . C7_ a.LL.�.. –u'di(J � n. �– i -- �o� � tn u. w _ =V ii w ---
_—'�