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HomeMy WebLinkAbout1618A 1619A (9) _ __ WORKERS'COMPENSATION OECLARATION � *„�,�.,,s y,,,,,.,n.�:,t„,yt�.�,,,sy,.;�= �.,:-.�� . � , .. . .. ._ .- ... � ..,,:. ,.. . .. I i hereby of£Irm Ihat I hove a certificale of Co�senl to se�4 qPPLICATIO�I�����P�C�R�� BU�i�Lb�+��VC� �PERMIT �� insure,ar o cerhfimte of Workers'Compensation Insuronce, � or co er 4(ec.3800.Lab�.�G.l� � . . . . . . �P���—��1�'—USl�b . � 60/E (2 Cdr) COUNTY OF!OS A�1C,ELES BUILDING AND SAFETY Nationwide "° PolicyNo. Company . , ....... _ . ..... .. ... .. . ,. .., : ,..,.;... . ��:a,�.�e . :.. .... . ., .;,.:,.. ... ..._� . � Certified copy is hereby f�m�shed. FOR APPLICANT TO FILL IN nooa°es"s 24423 Deepsprin S DY1V2 � Cerfified copy Is filed wifh the munty building inspea �auitDiNG no�deparimenl. AODRE55 2442 ee Dote $'18-87 Appliconi THE ANDEDT GROUP �� �iTV Diamond Bar na 91765 .;� iocnuTv Diamond Bar CERTIFICATE OF EXEMPTION FROM WORKERS' ��� � NO.OF s�DGS. ' NEARE57 COMPENSATION INSURANCE��- � �� - SIZE OF LOT NOW ON LOT ceoss sT.Ca io & Golden S rin S (This section need no�be completed if the permir is for one n55ESSOR-� hundred do�lars($100)or less.) TRACT 42589 BLOCK �or No. 65 MAP BOQK PAGE PARCEL OWNER THE ANDIIV GROUP No.967-9541 USE ZONE �� � I certify iho�-in the performance of ihe wark for which ihis �'(,.�J N�� ��r� �, permit is issued,i 56a1i noi employ any person in ony manner SPECIAL � so as to become subject ro the Workers'Compensation LaWs. FlDDRESSP.O.BOX 3329 U'V�- CONDinONS U CITV � ZIP � !�nte flpplicpnt DISTRICT GROUP NPE FIRE PROCESSED BY O ,.t� � � � ARCHITECi OR TEL � �TICE TO APPL�CANT: If, ofler moking thia CeHi4itote oS ENGINEER Dave Szany AIA No.445-4073 CONST ZONE f" .amption, you should become subject to Ihe Workers' � � - �.l �— (,) Compensation provisions of ihe Labor Code,you mus�forih- qDDRE55 314 N. First Arcadia 91066 d� �I� tl� � � with comply wilh s�ch provisi0�5 0� fhis permit shall be TEL. 5TATISTICA�CVSSIFICAiION- APT. CONDO. tn deemed revoked. CONTRACTOR THE ANDIN GROUP No. �!� �—� Z LICENSED CONTRACTORS DECLARATION �� . i��. an55 NO.JI�DWEu,UNIiS '�L_ I herehy affirm that 1 qm licensed under provisions of Chapfer 9 ADORESS AS d�JOV2 NO.SZOSEO SEWER M4P� � (mmmenaing w�th Section 7000)of Division�of ihe Business and u�. _ Professions Code,and my license is in full force and effect. CITV . CLASS $ BK � YALIDATION 510560 B si'ieF�2375 S ORI�ES FAMILOIES CONE ;�� �� ��n License Number Lia Class . ,,, .. . VALUATION � THE ANDEN GRj�UP 8-18-87 DESCRIPTION OF WORK Sin le famil NEw �] Conlractor �bate App � S 1�]i6QQ p#a o o-c?� �I am exempt under Sea GdYd 2 Sj.O SP' - A�TER � , � 'S 3�� � C 0.8P.C.for�his reason aevAie ❑ s �� �, � _ USE OF r"7 `� �' � �'`� Oa7e: E%IS71NG eL�G. DEMOL �J SignaWre APPtICANT 7EL FINAt /�i �'.i � ��7 OWNER-BUII�ER DECLARA710N��� �� � � PRiNT1 NO. DATE � .�J 1�.�3 I here6y affirm fha�I om eaempt from fhe Conirocror's License AS dkJOV2 Law for�he following reason(Section 7031.5, Business and ADORE55 .... . _.-. .. . .-.:,..,, Flrypl � _..,: �rofesaions Code): aae � BY '` � I, as owner of rhe property, or my employees wilh A�DRESS � �� ��-- ���•--��' � wages as thei�sote compansation,will do ihe work and � z j �)j,9� ihe structure is not intended or offered for sale(Set}ion �����N „�.-.." '-'`.'--:. 7D44,8usine55 and Profeasions CoCIe). MOVING . tEL �f m m-e o e j � I,as owner of�he properry,am ex[lusively mntracting CONTRACTOR NO. with li[ensed confracfors ro consfruc�ihe projecf(Sec- ADDRE55 . .._ � a�"�'�� tion 7044,Business and Professions Code). - �"' "�""` CONSTRUCTION-LEN�ING AGENCY �� ��� � SE46ACK �ARD HWY T�Tp'p0.0PB LfNEFR � Yd�DTH ' '�� �•��O� I hereby affirm that ihere is a constroclion lending agency for p2pNT � i:� � � _.�� the performance of the work for which,ihis permit is issued v.L � �Sec 3097,Civ.C.). SIDE � � Citibank P'` Lendei s Nome - LDMA Ref.k 444 S Flov�er, L.A. 90017 p,�,Fee S Parmir Fev � Lendei s Address � � I terti£y that I hove read this applicnlion and s�ate tM1at the Issuance Fee 10•50 IDMA p/C k above inform " n is mrrecL I agree tb comply with oll County inve:iigoiion Fee 567.Q� ordinonces 51ote laws relating to building[onstruclion, . Ta�ol Fee LDMA Perm.N ond here hori e�epresemafives of Ihis Co�nty to enter upo -m ' ed properry for inspe on purposes. � . . � � � � �`� LDMA �4EE REVERSE fOtl EXPLAN7ITORY L�GUAGE Signoluie of Applican�or Agen1 Da - ._��_.�._ .�_.m__ _.w_ � _._.__ . ..�.... ..,._ �.�.W.._w�.�._ _._..__�_m_.__._�� - .� .. t.,. ,x , __._ _,��_..� �.___'� � ,:._. _..�� i,..��:. _�,.�.. .;r:�: .� ,� „a �.______� .... . �. .� ��,. � �.-v : ;� . ;. _ .. , i r.�..;e,,s� . , . � _ _�__ ,. , _ , _..�._ ,,, �, , � �,:,>� � � � ., " � �" . � _x���. . , _ , :-� .c .,_�,� .,W., ._,.� .._. ...,- _;.y. _._._".____........._._.W. .._.__.__ -7 ..._. .__... _ . _ ...._.� _.... _...__.r_�.�__ ..........._'SW :�..�».w,.,-.�.:wi:,�..�•...�,...�.�..n„�. -�� r , ..__. .. . : r , ; � . . . . ,. .�.- . � '. .. .�.. 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