HomeMy WebLinkAbout1607A 1608A WORKERS'COMPENSATION DECIARATION �
I hereby offirm thot I hove a certifimfe of consenf fo=e�f � APPLICATION FOR BU�ILDING PERMIT
. insure,or o certifiwte of Workers'Compensotion Insurance,
o.o certif�ed m rhereof Sea 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING ANd SAFETY
73WC005-2P'�9-001� 35/C
P❑olicy No. Company Nationwide
Certified copy is hereby furnished. FOR APPIICANT TO FILI IN ADDRESS 588 AR[nitos Place
� Certified copy is filed with fhe county building inspec- BUIIDING
flon departmen�. AD�RE55
Dare 8-16-87 APPlicant T� �DEN GROUP c�Tv DlamOrid Bdx' z�P 91765 �ocn��Tv Dla[ROIld BdL'
CERTIFICATE OF EXEMPTION FROM WORKERS' SiZE OF LOi NOW ON�LOis CROSSSST. 10 & GO1C12S1 $ r1I1 S
COMPENSATION lNSURANCE
(This sec7ion need not be wmpleted if ihe permit is for ona ASSESSOR
hundred dollors($100)or less.) TRAQ 42589 BLOCK LOT NO. 73 AAa,p BpOK PAGE 7ARCEl
TF�' USE ZONE 1NAV � tf
OWNER THF+ AND+FL�T GROUP No967-9541 J� —'�
I certify tha�in the performance of ihe work for which}his �,� NO. i"
permit is issued,I shall not employ ony person in ony monnei ADDRESSp.�.BOX 3329 OEND710NS �
so as to become subject ro the Workers'Compensotion Lawa. Q�
aiv ziP V
�n1e Appllcanl , ARCHITECT OR TEL. DISTRICT GROUP TYVE fIRE VROCESSED BY O
� �iICE TO APPUCANT: If, after making ihis Certificale of �V2 .SZdTl AIA 445-4073
..empfion, you should become subjecl to the Workeri ENGINEER y N�� CONSi. Ar Z�IV F—
Compensation provisions of Iha Lobor Code,you must farih- ADDRESS 314 N. First Arcadia 91006 1 Q 1` �/T' � W
with comply wilh such provisions or this permit aholl be d
deemed revoked. �ON7RACTOR THE ANDEN GROUP TE�� STATISTICAL CLASSIFICATION APf. CON�O. (q
NO. q (� Z
LICENSED CONTRACTORS DECLARATION �i�. CLA55 NO.��DWEIL UNITS �
1 hereby affirm that I am licensed under provisions of Chopter 9 ADORE55 1�5 d}�OVA No.510560
(mmmencing with Section 7000)of Division 3 of ihe BUsjnass ond G�� SEWER MAP � �
Professions Code,and my license is in full force and efFect.. QTV CLn55 B BK � VALIDATIOH
510560 B s°eF'1531 TOR�B F MILOIES 1 CONEK --_••
License Num6er Lic.Class
(�(�T�p YAlUAT10N
ControCtor T�' �D� `"""p'a'Me $�l$—�7 DESCRIPTIONOFWORK.cil le famil NEW ]Q s ,70',700
�I om exempt under Sec. d e 441 SF ADD , =�'� b�,7 A
ALTER
8.8P.C.for thls reason REPAIR s �� � � •2�
Dare: us�oF oenno� I •�3 9.1 9
EXISTING BLDG.
Si noture APPLICANT TEI. � _
g OWNER-BUILDER DECLARATION PRINT No. pATE��j. G�/tf'�" °c:.9.� �c�
I here6y affirm that I om exampt from the Contractor's License � gijp� �
law for�he following reeson(Section 70.31.5,Business and ADDRE55 pryp{, �/J �9�� � `��7
�,,,�rofeasfons Code): N By `�y���
JBUILDING
I, as owner of the prope�ty, or my emplayees with qDDRESS
� wages as iheir sole compensation,will do the work and
the structure is nm iMended or offared for sale(Section �aA��TY
7044,Business and Professions Code), nnOViNG iE�. ."1 6 Q 8 A
� I,as owner of Ibe p�operty,am exclusively cantracting CONTRACTOR NO. #• . •�. e �
wi�h Ikensed controc�ors lo wmtruct the project(Sec- qDDRESS
tion 7044,Business ond Professions Code�. � ��1� 2.5�
CONSTRUCTION LENDING AGENCY REQUIRED yqRD HWY TOTAlSETeA K
SET BACK PROP.UNE �✓�DTH
I hera6y affirm tha�there is a cons�ruction lending ogency for FRONT • � �:1 2 5!7�
Ihe performonce of the work for which Ihis permif is issued P.l.
(se�.aoffr,c�.e.�. soe 0 9,1 1 —8 7
P.L.
lender's Nome C1t1baT1�C
444 S F10�W2r� L.A. 90017 IDMA Ref.N
4 P.C.Fee S Vermit Fee �
'p Lender's Address
5 I certify that I have read thls applicetion ond state that the issuancs Fee 10•50 LDM4 P/C M
above informatio corteci.I agree 1a comply wi�h all County Inresrigonon Fse
� ord7nancos on ta laws raloting to building construction, Total Fae 412.5� IDAAq perm.M
and hereby ri r presentafives of this County to enter
� upan i e en ropmly for inapecfion p rposes. ,
� � C �S
�fE�REVERSEfOREX►LANATORYLAN6UA6F
SlgnoNre of Applicant or Apenl pp�
PLAAS TO kP➢t1CAR7T INSPECTO�'S NOTES OW!�F':It-i31�1f.Il7�,R Dfi<�.I.ARAI�[(.1S
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