HomeMy WebLinkAbout1811A 1812A WORKERS'COMPENSATION�ECLARATION �
�ereby�affirm iha�I have a cer�ificate of conseM l0 5e�f � qpp��CATION FOR BUILDING PERMIT
ure,or o terfifimte of Workers'Compensation Insuronce,
a cer�ified co y Ih r of 5 3 ab.C.)
83-CKP 9��-��4�P�A AETNA COUNTY OF LOS ANGELES BUILDING AND SAFETY
IicyNo. �Compony_
� Certified copy is heraby furnished. FOR APPLICANT TO FILL IN nooeEss 24168 AVEN IDA RANCHEROS
7 Certifiad copy is filed with the county boilding inspeo- auaDING
liondepaAmenL ADDRE55 24-168 AVENIDA RANCHE �ocnuTv
rte 1/23f84 qpplicantTHE ANDEN GROUP ciTv DIAh10ND BAR ziv91756 ceosssT
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE S�ZE OF l0T NOW ON LpT �. MAP BOOK PAGE PARCEL
his section need not be completad if the permit is for one USE ZONE nnnP
rencr 3 3 Q 2 Q a;oc,c �oT No. 16 No. ��3—3 s�9
undred dollars(E100)or less.) TEL SPECIAL
certify that in the performance af the work for which�his OWNeRTfIE AN�EN GROUP n,o -9541 [oNo�710N5 �,
ermit is issued,I sholl not employ any person in any monner �ISTRICT GROUP TYPE FIRE PROCESSED BV ()
o as to become subject�o the Workers'Campensation Laws. AooRE55 1�74 PA R KV I E W �R, mN57. Z�Or l�
/O T.3 � 7�' t,
bte Applicant� . CITYC Z�P STA7ISTICALCLASSIFICA710N qpT. CONDO. C�
ARCHlTEC1 O ' . . . . '�'..TEL,
�OTICE TO APVUCANT: If, af}er making thls Certificate�of ENGMEER .�P.�VE �.S�F���'�� NO — � 7�'� �
:emption, you shauld-6emme �subject��fo the Worker§' , . . . �CL455�N0. - DwELL.uN1T5 ��
:ompansation provisions of The labor Code,you mus�forth- - � - - a�r-.
vith compty with such provisions or �his permit shall be �aooRESS 314 ]�] F I RS']' - 1($ � ,Q AD SewEe nnna
laemed revoked. CONTRAQORTHE f�.NDEN NO. � BK. f�G, VAkIDAT10N "
UCENSED CONTRACTORS DECLARATION �IC.
I hereby affirm thoi l om licensad onder provisions of Cbopter 9 ADDRESS 1��4 P A R KV I E W D R No. 3 71 S 8 0 VpLUATiON
(commencing with Section 7000)of Division 3 of the Business and ��c_
Professions Code,ond my license is in fu0 force and effed pTY C OV I NA C1n55 S 1��{�7 7 S ►
3 7 1 S S Q SQ.FT. NO.OF NO-OF CHECK
LICBnSB Number li[.CIOSS B SIZE 2 STORIES FAMILIES ONE
�7 NEW $
ConnacrorTHF. ANDFN (;R(11�?,�e t/�3�/Rd oEs�oN�QwoRK �
�I am ezampt under Sac. � I N F' ADD �
AL7ER � FINAi
B.&P.C.for this reason REPAIR � DATE � l� (���
USE OF DEMOL
Dore: FINAL
E%ISTING BLDG. gy l�y�_
Signatura APPLICAN? TEI. F
OWNER-BUILDER DECL4RATION PRiNi No. 8_ - � S�,� A
I hareby affhm that I am exempt from the Contractor's License qDDRES 10 7 4 Q A R KV I E W D R. C I N ► � ' ' ' '��
Law for the following reason(Sectio�7031.5,Business and
Prafessions Code):
�d"� 6UILDING � •�C.r7.7 7
� I, as owner of the property, or my employees with qooRESS
wagas as Iheir sole compansotion,will do Ihe work ood � F�2�'��?
ihe siruttura is not iniended or offered for sole(Section LOCAUTV
7044,Business and Profeuions Code). MOVING Te�. 0 2 2 n"�4
� I,as ownar of ihe properfy,am exclusively tonfrpcting NTRAC�OR NO.
with licensed contmUars to consrruct the projeU(Seo qDORe55 �n� &�.C k
tion 7044,Busineu and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY �7 gq�K YARD HWY PROP.LIN� WIDTH #' � � � � � �
I heroby affirm thai ihere is o tonsiruotion lending agency for FRON7
ihe performante of ihe work for which this permit is issued P.L /5�� ��/ � •J Jr�,n��
�sec.3ov�,c�.C.�. soe i
r.�. S /S� • � 54fQv�i
le�der's Nama
lander's Add�ess P.C.Fee a •��,S: 7',f vermn Fee .f�7.5`C� 0 2 c 9—�4
I certify that I have read this applicotion and staro ihai ihe Issuance Fee /d• .SQ
abova information is mrrett.I agrae ro comply with all Counry ���estigorion Fee ���
ordinonces and$mte laws relating to 6uilding conatrottion, IDml Fea ��
and here6y outhorixe epresentativas of lhis County to enter
u e a6ove-men ned property tor insps�ction porpoces.
L—�`S' SEE REYERSL FOR EXPLI1NAiONY LAN6UAGE �
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