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HomeMy WebLinkAbout0888A 0889A (4) � , . _ . . . . ... _. . .__ _ .. _ __._..___ ._ . . . .._ ._. _ WORKERS'COMPENSATION DECLARATION '�'� � ' �� •- '" �' . Z . . . � _._..... � . . � ��;��e or�oFcertifca�leofWorkcrs'fCom�pensaion��5�',a��e` �APPLICATiON_ FOR BUILDING PERMIT � or o certiticd copy�hereo((Sec.3800;La6.C.J� � - ' �� � �� 61WETX7993 Hartford'Group GOUNTY OF LOS ANGELES BUILDING AND SAFETY � � PolicyNo. Company BUIIDING / Q �Cerrified mpy is hereby furniihed. t . . � POR APPLICANT TO FIL!IN ADDRESS '� 3' �. n-�'^t� � Cerlified copy is filed with the�ounly build'hg indpec--/' � BUILDiNG . v , ro�de imen /J ADDRESS 24437 East Thunder Trail ' ` �� Diamond Bar-" -� Dafe' ApplimM G � �r CITY ZIV .... IOGLIiY � '' CERTIFICATE OF EXEMPTIO FROM WORKERS' �„ � ' '�' � � - NO:OF BLDGS. - --- � �- NEAREST ' � � � COMPENSATION INSURANCE' � �� SRE Of LOi NOW ON tOT CRO55 ST. � (TBis detlion need nol be completed if the permif is for pne � 72ACT 4Z�JFIH '1 BIOCK LOT NO. /' MAP BOOK'� � - PAGf PARCEI .hundred dollars(5100)or 1ess.) .. ,.,, -, , TEL. I) .. , . ... �•,.. .. ,. . ... .- OWNER ' Bl"a�ll � �111� NO: ��� E �P ' /l�� I cenify that�in��6e performance ot the work for which�his ��� �� > permit is issued,I sholl nol employ any person in any monner _ . ���A� "-- �- � - � - �Q so'o�to become'subject to the Workers'Campensalion Laws. AD�RE55 Od� CONDITIONS V �.. � arr zia . � Date ��' � ' � APPlimnl� .• .� ..., � f iEL � I 7ICE TO APPLICANT:�If, alfer-moking-�his Certificdle of ARCHRFC DiS7RiC7 GROUP ttPE._� FiRE PROCESSEDBY 1np�ion, you should becoma subject to �he Workers' �� ENGMEER NO. - COry �!�E ~ Compensalion provisions of ihe Lobor Code,�ypu mv51 Forth• qDDRE55 3990 Westerl Pl SU7 t2 ��� �� - -� - �.f-^ a wiffl COmP�y w��h Su[h provi5ionl or ihis pe�mit sholl be- 7E1. STATISTICAL CLASSIFICATiON APT. CON00. � deemed revoked. � ,� � CON7unCiDit � NO. - �L Z UCENSED CONTRACTORS DEQARATION- �'� � � � - �i�, - ��CtASS NO.��-� � DWEIt.UNRS �T / I heroby offirm that 1 am licensed under provrsioas of Chopfer 9 nooRess ��3151 Ai rwa Ave. N No. 40961� gy,�R�qP (mmmencing with Section 7000)of Divrsion 3 01 ihe Bosiness ond . . _ _ .. .. .p�.... .� � FroFessions Code,ond my license is in fuil foice and effeU. Ctiv C1A55 "" BK- -- �' ' - YAIIQATION -' ' �� ' Sq.FT. NO.OF NO.OF CMECK � _ �license Nomber 409610 i��.�dass� ' B -' size sroeies FAMILIES - ONE � • � � /�jc/ v�wanoN ;�C 8 Q 8 A ' . . . .. DESCRIPTI�.JC`FM/ORK . ..� .. N� 11� �0� � Confraclor � � Dale ADD � s ) ;;c • o .2 1 �I om e•empl under Sec. � - S1 fl �Q F8�111� .RQSI d@�1Ce -- - AITER � ��, w��� . ' s I •JLla6C I B.BP.C,for fhis reason _ REPAiR.� � -�- � �"- : � � � � USEOF Q + o,'-_,(!;,�?� Dale: F%ISTiNG BLDG. DEMOI ( �� Signolure �� APCLICP.NT .. .iEL. . . . . FINAL ' .' _.. . — . O C'�O`F��7 O NER-BUILDERDECLARATI vRiNT Geor e Vedell No. H5�-�OO�'� ..DATE I hareby offirm�hat I am ezempt from�he Con�mclor'a License pDocE55 l 1 Ai r {� HNAC � � " Law for the foliowing reason{Section 7031.5,Business ond 7 _ _ . __ Professions CodeJ: - ' � - �- " - ' aR N dy �� _ � • , � . BUILD'NG ' . __' ' ' "' I, os owner o(ihe property, or my employees wfih ADORESs . � � wages os their sole compensation,will do the work and � � :%Q��a . H . tfie x!ructure is not inlended or ofiered for sole�Section ��`L�TM � � ' 7044,Business and Professions Code).' ' � -- MO�NG � " " " " -�� �� TEt. � � ' "- . � ' ��-e"e'� c e � � I � CONTRACTOR NO. . . ... ' . I,as owner ot Ihe property,om exdusively contmcting -wiih licensed conlrotlors fo[onstruct Ihe pro�¢U�Se[• qDDRE55 � °:G E'�G I �ion 7044,Bueiness and Pwfessions Code). .. � : � .QEQIIIRFD IUTAL SEiBACK F M.. . 1 „�{'j.4..n S �CONSTRUCTION LENDING AGENCY SEi BACK ��ARD �HWY PROP.LME N/IDiH ���� �. I here6y offi�m fhaf there is a construttion lending agenry for FRONT - - �. �� ' � . • � . . . ,�- -' f� ._n -tha periormonce of ihe work(or which�his permd is�ssued --- -P.l.�-�-� �-�- -- � - - ' ------ --�-- '- --�--"" " " ��•: ��' C�-- {Sec.3097,Civ.C.). SiDE ' ,, � Toronto Dominion Bank - �- ``' - - - - -- m Lender's Nome �J 7 (�' IDMA Ref.k , : � ' a 144 Sansome St.p �lll t@ JOO . ._, p,[,Fee f- J J'��- Perm��Fee �� �'J V- - -- _ , , = lender's Address • � ' �� i � '_` l0•� .. � ; � I.certify thoi I hove read ihis opplication and sia�e ihot tha . .. ... . _ .�S�vU - iesuence Fea� � - - -- iDMA P/C M- .� - '� �. � � ¢ obove iniormalian is corred.I a9ree 10 comply wilh all Coony invesrgaron fee . , . ' g ordinancee ond Slale laws rela�ing to building construciion, To�al Fee--�SS D��� - LDM11q Pe�m.X -� , . , . � and hereby o�ihorize�epiesen�a�ives of this Counly�o eMer �� g upon fhe abave-men�one prop t (or InspecNen pvrposes. _ � � _ . _ 3s'---= //11 _ -__ . a' � ������ " .� SEE REYERSE fOR EXPLANATORY LANGUAGE ;��-' � .- 4 , ,_ ' . .„ � _ . u ol t e .�. _ ....._ ._. _.. __ ._..._- � -- - . . ... ..' -- .- . -_' _ .. 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