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HomeMy WebLinkAbout1809A 1810A ,.WORKERS'COMPENSATION�ECIARATION �} •I hera6y affirm that I have a certificate of consent to,e�f /�,pPLICATION FQR BUILDING PERMIT '�� insure,or a certificate of Workars'Compen5ation Insurance, �' � or a certified copy thereof(Sec.3800 Lob.C.) PolicyNo�C K-956 �IOP�y I5A AETNA p COUNTY OF LOS ANGELES BUILDING AN�SAFETY � Certified copy�sha�a6yfu���shed. FOR APPUCANT TO FILL IN nooREss 2416 AVENIDA RANCHEROS � Certifiad copy is filed with the co�nty building inspec- BUILDING tiondepartmenf. ADDRESS 2416 AVENIDA RANCHEROS �ocAurvDIAMOND BAR 1 23 84 THE ANDEN GROUP NEAREsr Date I I npplicanr ciTr DI MQND BAR ziv 41756 cRosssT.GQ DEN SPRINGS CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF Bi�cs. n55e550R COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT 1 MAP BOOK PAGE FARCEL {This section naed not 6e complered if the permit is for one USE ZONE MAP hundrad dollars(a100)or less.) TRACT �j 2 BtOCK LOT NO. 1 No. /.�3-- �,.r TEL SPECIAI I cartiiy that in the performance af the work for which ihis OWNER'j'j-j� ANDEN ROUP N -9541 CONDITIONS 4 permit is issued,I shall not cmploy any person in any manner DIS7RIR .GROUP NPE FIRE PROCESSED BY � so os to become subject to ihe Workers'Compensafion Laws. NDORE551 {�] n CONST. ZONE J r ciTr COVINA ziP 91724 !� �`3 � G2 Oate ApplicpM� . . . . . STATISTICa.I ClAS51FICATION APT. CONDO. 1— ....�-NOTICE TO APPLICANT: If, aflar maki�g�his Cartificate�of °'�y�7Ea oe � .�-..TFi. .. �. .emprion, you shauld become subjecr to the Workers' EN��n�ER DAVE SZ NY No -4073 cuasNo. crao. wveu..uNirs�� � ,:ompensarion provisions of�he Labor Code,you most forth- qoneess314 N. F I RST AVE ARCAD IA CA sewee hwP 9'� with comply wifh suth provisians or This parmil shall be . _, f3eemBc�fevokecJ, CONTRACTOR TE`o. -�9541 BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION � ii�, I hereby affirm}hat I am litensad under provisions of Chapter 9 no�a�ss l R 7 4 PAR KV I EW D R..No, 3 71 S 8 0 yAlUAT10N (commencing with Sacfion 7000)of Division 3 of the Business ond LIC. Aofessions Code,and my license is in full forte ond eRec1. CITV C I CIASS $ E��s 9�� , ' SQ.Ff. NO.OF NO.OF CHECK License Numbar����+Q n Lit.Class R Srze 1 S 3 6 sioe�es 1 FqMILIES 1 ONe ContractorTHR ANDF.N GROI}R,�e 1/23fR4 oEs�i ro��WORN NE''�' � E �I am exampt�nder Sec. r �[ F SINGLE FAMILY HOMES ADD ALTER ❑ pATE •�f l�(�' 1 B.BP.C.for this reason REPAIR ❑ Date: USE OF FINAI EXIS7INGBLDG. DEMOL ❑ By I��f,� S�9oar�re PPPLICANT TE`. �_g 5 41 OWNER-BUILDER�ECLARATION PRINT THE ANDEN GROUP NO. I hereby affirm that I nm axempt fram the Contractor's License , �r�� Q Q 9 A Low for the following reason(Section 7031.5,Business and ADDRE55 � � Profassions Code): �'-� ��� � ...,� BUIIDING I, os owner of the property, or my employaes with ADDR[55 � •G.�i 7.C!�l wages os their sole compenwtion,will do ihe work and ihe structure is nm intended or offered for sale(Set�ion �OCA��TY � • a C 5 7.9 r.��. 7044,Business and Professions Code). MOVING TEL. � I,as awner of the property,om exdusively mMracling NiRACTOR NO. 0 2 2 G��U- with licansed contracrors lo consiroc�the projecl(Sec- qooaes5 �ion 7044,Business and Professions Code). �:� FS�.G A REQUIR€D TOTAL SETBAIX FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY ppoP.IINF WIDTH I hereby affirm�hat there is a construction lending agency for FRONT � ��� � � � � � the performance of the work for which ihis permit is issued � P.t. �'�'� '�' � m L(4 G���Q (Sec.3097,Civ.C.). SipE � r - P.i. ✓r . /.�' =ti-4 G 0 0� Lendar's Ncme � �ender's Address P.C.Fee E S�J. Permit Fee � `Q a?2 9_�4 � I ce�tify�hat I have read�his application and state thm the isw �e Fee O•.S U above information is correct.I ogree to comply with.all Counry Investiqaiion Fee �� '` ordinantes and State laws relating to building tonstruttion, To�al Fee Y�� Pn Y1 cnd heraby authorize r resentatives of this County to enter � u e above-men' operty for inspection p/urpoaes. � � �l�� SFE RLVElSf FOR El(MANATORY IANGUAGF Signaru of Applimnt gen� pote �� ._� �.�.�_____�. ��. __ _ ._�� .�._._. �, � ow�. �.a:� � • _._ __ .� »�.� ��V -- � _,_.� m.._ . .. � . �� � , I r�: � raa�:..►� _ , , ,�. c y_ �o s� �_ � � ---� -- �-- -- ' ,�3 .t• � � �_ ,_...._ .v_—. —_ ._.._ __ _.._ _. , n. .. �..e.� '�- � 7�. � F - . . ,c. � -��.z� _._ . _.. .��..�.:: . .�� ___,_ ..___ .... _ . ... . -:. _____'____"—_______ ' __' '_.__-. _.__ , ... ..;.�r�7r'sros .� _._ . � ��._ . ,._ .i ���I ; r-. ��� 1�� y{�e�i i _____.—_-._-._ , . , ,. _.- .—._._.I,.--s��� _..�.'___`_ ' _____ ____. _ . _. of . nir I i� �! � . � � � � u�.�iYr�s SE ___. -- :..- ----- ... �- --- �--_.._� --- . _._ ____. .-_ -- . 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