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HomeMy WebLinkAbout1805A 1806A ,WORKERS'COMPENSATION DECIARATION �� I here6y affirm that I have a certificate of consent to self �� APPLICATION FOR BUILD�NG P��1�1[C�'� insure,or a ceNificote of Workars'Compansation Insurance, � or a ceni4ied c�op y thereof(Sac.3800 Loh.C.) 8 3-C K-9 S 6-10 4-C�A COUNTY OF LOS ANGELES BUILDING ANO SAFETY Q�yNo, compony AETNA BuaDiNG Ce.rffiad copy is here6y fum�shed. fOR APPLICANT TO FILL IN ADDRESS 24166 AVEN IDA RANCHEROS � Certified copy is fiVed with the counry 6uilding inspec- BUILDING no�department. noortEss 24166 AV�NIDA RANCHEROS �ocnurYDIAPIOND BAR oo,a.�[.�3Jua ApplicantTF7F, ANnFN r.urnip c�TY DIAMOND BAR Z,P 91756 c"RossSsrGQLDEN SPRINGS CER7IFICATE OF EXEMPTION FROM WORKERS' NO.oF etoc5. a55eSsoR COMPENSATION INSURANCE SIZE Of LOT NOW ON l0T 1 MAP BOOK PAGE PARCEL (This section naed no1 be completad if the permit is for one 33020 USE20NE MAP j� �/ hundred dollars($1�D�O�IB53.) TRACT 6LOCK LOT NO. ]3 NO. � �T TEL SPECIAL I certify�hat in the perfarmonce of the work for which this �'�'NER THE ANDEN GROUP NO -9 41 CONDITIONS C.. permit is issued,I shali not emplay any person in any manner DISTRICT GROUP 7YPE FIRE Pi20CES5ED BV G so os to hacome w6jecl to the Workers'Compensation Laws. +�DDRfSS�O�I4 1�R�( 1 E W DR. coNs� ZOy( V a�r COVINA zir 41724 r� '�� `f '�'' t3 Date Applicant � SranSTiCA�c�n55iFiCAiioN APT. CONDO. �N .ORCHITECT O ��.:TEL. � ,--NOTICE TO P;PPLICANT: If, afiar moking this Certificate�oi � ENGWEER �AVE. SZANY.' No, . -4Q7.3� ��.einssNa �6`0�. oweu.uNirs�� �:-3 aemption, �yau should become �subject-ro�the Workers' � . . . � �, .:ompensm�on provisions of the:Labor Code,you must forth- noo2E55314 RST AV E: ARCAU TA C sewea nnAo s? with <omply with soch�pravisions or this permit shall be TE�. �- deemed revoked. ' � CONTRACTORT D R No. 41 BK� �� VALIDAtiON IICENSED CONTRACTORS DECLARATION IIC. 1 hereby affirm thot I vm licensed under provisions of Chapter 9 ADDRESSJ.O 7l1 pAjt I$j�f D[Z. NO. 3'j 1 S 8� VALWTION �commencing with Saction 7000)of Division 3 of Ihe Busineu and ���. Professions Code,and my licrose is in full force ond effect. Ciie CLA55 s 64 8$0 , S0.FT. NO.OF NO.OF CHECK License Number '�7 l S A(1 Lia Class R SIZE .15 Q� STORIES 1 FAMIUES 1 ONE ConrrcscrorTHE ANDEN GRQU�,�e�..[23/84 oeS�6ric�WORK NEW � E ❑�emexemptunde�5ec OP SINGLE FAMILY HOMES a�o ALTER � FINAL n�� ��� B.BP.C.4or ihis reason REPAIR � DRTE USE OF FINAL ��1e' EXISIING BlDG. ��"��i � sY ��,u,�+i �� �C.5�i Signature . APPLICAN7 TEL � OWNER-BU�IDERDECLARATION PRiNT THE AND$N GROUP No. -9541 #� • • •21 I here6y affirm that I am exempi from the Contmdori license App� 10 74 P A R KV I E W D R. C OV I NA C, i �� •2 2 3.i 3 law fo�ihe following reason(Section 7031.5,8usiness and Professions Code): ,,.� BUILDING • •2 2 3.1 3� I, as ownar of the property, or my emp�ayaes with qpprzE55 wagas as fheir sole compenwtion,will do�he work and L��n, 0 Z 2 9—8 4 �he structure is not In�endad or offerad for sale(Section 7044,Business and Professions Code). MOVING TE�. .-s 1 fi 0.6 A � I,os owner of ihe property,om ezclusively conlraciing NiRAQOR NO. . . • with licensed comroctors to construct the prolect(Sec- ii��• • � tion 7044,Business and Professions Code). ADDaE55 REOUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDWG AGENCY �T Bq�K VARD Hwv p�p��NE wIo7H � I •.5 '� ,S O 1 hereby affirm�hm there is a consiruciion lending agency for pRONi the parformonca of ihe work for which ihis permit is issued P.�. �� S�� • °�t`�,rJ l7�i �Sec.3097,Civ.C.). SIDE � �y f i G 2 2 9—8 4 - P.L. Lander's Nome ? S P.0 Fee$ ,f� �J Permit Fee �7��� Lender's Address � I certify that I hava roed this applicatfon and stme that the iu„ �e pee (7..S'V � o6ove informotion is correct.I ngrea lo comply with ol�County invesiigation Fee a� ordinancas and State Iaw relating to building construction, Torol Fae �-+CJ G and hereby au+horize re sntativas of�his Co�n�y fo en�er � upo above-mentio roperiy for inspectio�purposes. � �ti ! SFE RlYflRSE POR EXPLANATORY lAN6UAGE ' Sig�.�aur H ant or P�sn� ote �� � N � . __._�_��� .�_ _ _._�y� _._ _�__ ���T..a._�--� IF.� i �.._, . ,.. I 7 � . ...,_. . .rr�� � ��wvt..- w .,..,. �.,.. 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