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HomeMy WebLinkAbout1609A 1610A (9) .._ . ___ _. WORKERS'COMPENSATION DECLARATION � � �, � �� � ' . .._... . .,. ,.. ..-. ._.. � ... ....... . :..�> I hereby affirm �ho7 I hove a certificate af consent to self AppLICATI�4N���FOR��BUf�L`bI�NG���I���M�IT� � � insure,or o ce�tifimte of Workers'Compensation Insurance, ` or o certif ed copy rhe�eof(5ec.3800,lab:C.) COUNTY OF LOS ANGECES BUILDING AND SAFETY 73WC�.005-279-00J�6 35/B Palicy o ompanY-Nc"ltlflYlWlf�P . . ... .._..._. . , ... _.�.: . . . Ce rfied co is hereb fumished. ���� �� � � 6UILDING . � � ❑ PY Y FOR APPLICANT TO FILL IN ApDRE55 24427 Dee s rin s Drive � Certified copy is filad wifh the counry building inspeo BUILDiNG tion depariment. ADDRE55 Dare $-1$—$7 qpplicanr THE A1�7DEN GROUP arv Dlamond Bar z�a 91765 �ocA��Tr Diampnd Bar CERTIFICATE OF EXEMPTION�FRONi WORKERS'-�-�"�� � �� � NO.OF BLDGS. NEAREST . COMPENSATION IN5URATNCE ���� �� � ��� 5¢E OF L07 NOW ON LOi - CRO55 ST. • (?his seUion need no1 be completed if the permit is for One - � ASSESSOR � � TRACT Q.2 9 B�pCK lOT NO, hundred dollan($100)or less.) MAP BOOK PAGE PARCEL nio967-9541 use zorve nw.a I certify that-in�he performance of ihe work for which this owNea THE ANDEN GROUP� No. IrT-3 permit is iss�ed,I shall nof employ ony person in any manner �/ SPECIAL � �r so as fo become subject fo fhe Workers'Compenspfion Laws. ADDRES `(J"C�� CONDITIONS o �'�te. . APPlican} � QTV ' ZIP ...� U ARCHITECT OR � ' TEL. '"'" '' � 710E TO�APPLICaNT: If, affer making fhis Ceilificate of ENGWEER Dave $ZdTl AIA No.445-4073- oisrRicr GROUF 7VPE FIRE PROCESSED BV � .emption, you should become subject to the Workers' CONST'�N Z Compensation provisions of ihe Labor Code,you must forth- qooRE55 �U �'� ry U with comply with such provisions or this permit shall ba � � TEL d- deemed�evoked. STA7ISTICAL CIASSIEICATION � APT. ONDO. Z coNrRnaoR THE ANDIN GROUP NO. � LICENSED CONTRACiORS DECLARATION ���, CLA55 NO. 'V DWE�L,UNI75 — I hereby affirm thot I am licensed under provisions of Chapter 9 ADDRESS Np, -� � (commencing with$ettion 700D)of Division 3 of the Business ond ��� SEWER MAP�� � Professions Code,and my license is in full force ond effect. aTv ClASS YALIDATION LiCenSB N�mber 510560 - sQ.�Fr. No.oF NO.OF CHECK BK' �'' Lic,Class B SIZE 1531 STORIES- FAMILIES 1 ONE TH� ANDEN GRO�T�e H-1S-H7 DESCRIPTION OF WORK � � NEy� � VALUATION �'�7 h(�,9 A Confrac�or ADD � S 70��OQ i9 b � a o 2� ❑I am exempt under Sec. 441 SF �� . � - ALTER � s I -�C�%.� 9 8.8P.C.for fhis reason REPAIR � Date: EXIST�ING BLDG. DEMOL Q a �.��`^ � a� Signafure APPLPRINTI � NO.:��. . . .....' FINAL G�i� L 4,� 1 ���/ OWNER-BUILDER DECLARATION DATE ��5 r/� I hereby offirm iha�I am exempt from the Contraaor's Licznse � �OV2 Law for the following reoson{Section 7031.5, Business and ADDRE55 FINAL � _Erofessions Code): � BY ��3� � �� I, as owner o4 1he propeny, or my empioyees wifh ADDRESS - wages as their sole compensation,will do ihe work and � �� E i�v i1 1he sPructure is noi in�ended or offered for sale(Section IOCALITY . „ ,,._ 704a,Business and Professions Code). MOvwG ��.�� �� � � *� 6 � a i � I,os owner pf fhe properly,am ex[lusively confracting CONTRACTOR NO. with licensed contractors to construct the�project(Sec- qDDRE55 � c(t f [,,S� tion 7044,Business and Piofessions Code). -��� ---..-.�-. CONSTRUCTION�[EM6ING AGENCY����-��- � ���� SEQeACK YARD HWv T�TA�SE7BACK F . . - • ., -., r;:_ CROP.LINE WIDTH ° t i i J !hereby affirm that there is a construction lending agency for FRON7 V fhe performonce of fhe work for which this permit is issued P.L. �i y ! i _.�� (Sec,3097,Civ.C.). SIDE Lender's Name Citibank P'� 444 S Flower, L.A. 90017 p C Fee s 239.19 Permit Fee 402.00 `o""°Re` # � Lender's Address � � ' � I certify tha�I have read this appliwtion and sta�e that ihe issuonce Fee 1�.`JO tDMA P/C k ' above info�motio is correct.I agree to comply wifh all County Investiganon Fee 412.5� 'q ordinances a ate laws relaling fo 6uilding<onslruciion, . 7owl Pee LDMA aerm.N and hereb ori e represemolives of ihis Co�nly to enter upon t -me roperty for inspec!ion purposes. � ��� ��� . . . � LDN11�. $75 $35_ "f SEE REVERSE FOR E%PtAN�ATORY�IANGUAGE � Signoiure of A p icant or A9e^� Da+ � n_-_..___M....._.__. �_. .� �._..�_�_._.____.�__�.._�__.--__._._.. �._ ��.,__,.�.____.�.�._�,.._p _ _ _..,Y<.. i _�cr'. . `rt';T�� .541��..c„ .�:_i�. . i,�r.s s��:':7\ �_ . . �;..� . ,�•,.__...._».,,_..,.�. �.,__,._.-�...,.,.._-�-.�....,._... .._..,.�;� � . . . . , . .. .�...... �..4�...�............ .._......-.�._.. ��. ..I �,.._...._�.._.-..-..m._.�... i ; �. .._.- .... .. 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