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HomeMy WebLinkAbout1626A 1627A (9) WORKERS'CONIPENSATION DECLARATION- � � - � � --- ��������� �������"�- -"�� -��� � � r � I hereby aff7m that.l have a certificate of consen�to se�f � AP-PLICATION �FO�R� �BU�ILDING PERMIT LJ insure,or o certificote of Workers'Compensation Insurance, � or a cerrified co �thereof fS�ec.3�600;Lab.C.) � � � � Pa 3VJN005-�'�9-OOCo pany Nationwid _ 10/B COUN7Y OF LOS ANGELES BUILDING AND SAFETY � Cerified copy is hereby fumished. FOR APPLICANT TO FiLI IN � A�REu 24419 Deepsprings Drive � Cerlified copy�is filed with ihe coumy building in5pet- gUILDING - � f�o�depaHment. ADDRE55 24419 Dee s Y'in s Drive oore 8-18-87 APPlimnt THE ANDEN GROUP aTv Diamond Baz' Z1P 91765 i�AiiTv Di�mond Bar CER7IPICATE OF EXEMPTION PROM WORKERS � NO.OF BLDGS. NE4REST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT - � CRO55 ST.CdY�110 S GOICZATl Springs �- � (This settion need nol be completed if the permit is for one� iRACT 42559 BLOCK LO7 NO. 66 AUES50R � � . hundred dollors($100)or less.) .^M+P BOOK PAGE PARCEL THE ANDIIV GRQUP TE�967-9541 us� o� nv.a `{ I tertify lhot in ihe performance of ihe work for which this OWNER NO. � NO. ���'� � t'C permit is issued,I shall not employ any person in any manner ADDRESSP•O.BOX 3329 .�-� SPECIAt � sa as fo 6ecome subject�to the Workers'Compensafian Laws. CONDITIONS O CITY L'OV1Ild ZIP 91�]22 � daafe Appliwnf. ARCHITECTOR 7EL. � �`r �TICE TO APPLICANT: If, after making�this Certificate of Dave Szany AIA 445-4073 DiSTRiCT GROUP NPE FIRE PROCE55ED BY O . m }iOn, � ENGINEER NO. a p yo� should become sub'ect to 1he Workers' CON`�Si.t ZONE � Compensation provisions of the Labor Code,you must forth- AD�RESS 314 N. First, Arcadia 91006 �� �^� y Ay �r 4t ith tomply with such provisions or this permit shall be . ''" deemad revoked. THE ANDEN GROUP TE�' STATISiICAL C1A551FICATION � APT. CONDO. � CONTRAC70R NO. ¢� z LICENSED CONTRACTORS DECLARATION ��� QASS NO. �� DWELL.UNITS�.L1� - I here6y affirm thal I om licensed under provisions of Chapter 9 ADDRE55 �15 dbOVe Np,S1��j6� (commencing with Section 7000)of Divisio��3 of the Business ond ��� SEWER MAP Professions Code,and my license is�in full force and effect. CI7V Cta,55 B � VALIDATION SQ.FT. NO.OF 'NO.OF CHECK gK� �'' License Number 510560 �;c.Ciass B size 1440 �sTORies Fa,nvues �- ONE VALUATION� THE ANDEN GROUP H-1H—B7 DESCRIPTION OF WORK Single family NEW � s 67,500 Comrocror Oate ADD � , c I ���S�G ❑I am exempt�nde�Sec. Gara9e 47� SF ❑ ALTER j,��.`:b o�� B.&P.C.for fhis reason .. REPAIR ❑ _ �ate: USE Of DEMOI i �r J f, I b EXISTING BLOG. ❑ _ ....._ -. � e�J I, i 6� Signature APPPRNITT THE ANDIN GROUP NO.� FINAL �i OWNER-BUIL�ER DECLARATION DATE -�' �v I here6y a4firm ihat I am ezempt from the CoNractor's License F:S cI�JOV2 �/J ?J 4,i i —�% Law for the following reason (Section 7031.5, Business ond ADDRE55 p�typ� �4��""" Professions Code): p � By ��4�� I, os owner of ihe properfy, or my employees with ADD E55 � wages as their sole compensation,will do the work�and , fhe strucfure is noi intended or offered for sple(Section IOCALITY 7044.Bosiness and Professions Code). MOwNG iE�. � I,as owner of the property,om ezdusively mntractinq CONiRACTOR NO. r% � �i C.,���l wirh licensed contracrors ta consrr�ct ihe project(Sec- qooRESS - � 7 , tion 70a4,Business and Professions Code). • " " ° kEQUIRED TOTAL SETBAIX F M � Y`)���� CONSTRUCTION LENDING AGENCY � SET BACK YARD HWV pROP.IINE WI�TH � � I hereby affirm tho�ihere is a mnstruction lending agency fo� FRON7 the performance of ihe work for which ihis permit is issued P.l, ry Q�J��` (Sec.3097,Civ.C.). SIDE .� Lender's Name Cl't].bdT1�C. P.t. fJ�':� I '-�7 444 S Flower, L.A. 90017 �onnn Re+.# � Lender's Address P.0 Fee S 231.16 Permit Fee 388.5� ' � I certif that I have read this a limtion and stafe that 1he Y PP luuance Pea �.0.rJO �DMA PiC# obove informp" is correct.I ogree ro comply with all County Invesrigarion Fee ardinances Slafe lows reloting to building construction, Tmol Fee 9 LDMA Perm.$ and here thorize representotives af this County to enter upon th e-m d properly for inspection purposes. � - SEE REVERSE FOR EXPLANATORV LANGUAGE ~ Signo�ure o Applicom or Agent � p�� �.__..�._...____ ___ _ .�...__..�__._�,w.e.�__�a.�..�._..�...��... ,_,�..___.,.�.�_.w�w.�..�__ ^.k�^ C,,.?*"l'e.`.u��.' �4 :,p.�C"s"5 �;l��n.,t�!�(�tl.1 ct ),'.�I_-�' 'C:I'�' .... . . .. , ,�. tin u :_. :._.._ . .m '..m-..-. ,.. . .: . . . . .. _ . � r,.;� ,:vea � �._'_.____� __.�_ ._,_ _..__,_ _._._.__� �_..... .. �,ri `.� r P a i, ;i _'_ _� "'....._.. �..._ _.... .. _ . _. is . 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