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HomeMy WebLinkAbout0776A WORKERS'COMPENSATION DECIARATI9N � . , - � � I here6y affirm that I have a certificate of conseN to self ,� . . qp.pLICATI�tV �_�C�R:::_;BUIIDING .PERMIT� insure,or a certificale of Workers'Compensqtion Insurance, ora certified copy ihereof(Sec.380tl,Lob:'C) " COUNTY Of LOS ANGELE5 ¢�B ' yN73WC005.-279�00�16 Nati,onwide 1/C UILDING AND SAFETY Polic o. om an � Ce�tifled copy is hereby furnished. fOR APPLICANT T�TFI'CCEN` ' `"'"`" Bu����N� AODRE55 �❑� �Certified copy is filed wi1M the munfy building inspec- BUILDING - � � � � . .fion deparfinent. ADDRE55 506 Dole Court. Daie �I$I8� Appliw�t THE'.ANDEN GROUP� �in Diamond Bar ZiP 91765� � � � ioG,i�T� Diamond-Bar � CERTIFICATEOF��EXEMPTION�FROM�4VORKERS' NO.OFBiDcs. NEAREST � � COMPENSATIONINSURANCE � S¢EOFLOT NOWONILOT - �� CRO5557.� D18IDO11C1 $2Y' :$T.V(�.. Golden $ Y1.Il S (This seaion need not be completed�if Ihe permir is for one TRACT -- 425��9 BLOCK LOTNO. 56 �FSSOR� �� '� � hundred dollars($100)or less.) N✓+7�BdOK�� PAGE PARCEL . 7Et. US O � � � A � owNee THE ANDEN GROIIP No.967-9541 I certify fhat in the performance of ihe work for which this � � �NO. /�� �3�' permit is issued,I shall not employ ony parson in pny mpnner . qODRE55 P.O, $OX�.332.9� � �LTqd17 SPECIAL � � � �' o so�as to become subje[t to Yhe Workers'Compensatiorvlaws � CONDITIONS � � `�*,ie ` . ':: Appli<ant � : �.�.. .. .�. � � CITY " . . - 21P - � ARCHITECT OR� - TEI. .OTICE TO APPLICANT: If, offer mokmg�Ihis Certificate of ENGINEER DaV2�$Zdriy AZL� NO 445-4073 DISTRIC7 GROUP �E �IRE PROCESSE�BV o Exemption, you shoold bemme sub�ect to the Workers' - �� � -�- � �� � �����--� �- —� ���- �1 yqS/��^^� Compensation provisions nf the lobor Code,you musf forih- ADDRE55 l� F'� CI1d 1 �� �1 3 `` '`� � �-1 winc �omply wilh such provisions�or this.permit shall be . � � . deemed revoked. -TE�� STATISTICAL CtAS-FICATION � - � APT. CONDO. Q' conrrRnaoe THE ANDEN GROUP rvo. N LICENSED�CONTRACTORS DECLARATION � - � . ���., CLA55 NO. - DVJELL.UNITS �� I hereby affirm that I am Iicensed�nder provisions of Chapter 9 ADDRE55 � �� NO. . (commencing with Section 70DO)of Divisio��$of fhe Business and LIC. SEWER MAP� - . Professions Code,and my license is�in full�force�dnd effed. CITY � ��LLA55� B BK � � VALIDATION - � �� �' SQ.PT. 1S�3S NO.OF � Z NO.OF 1 . CHECK - �LicenseNumber S1f1�SF,h Lic.Class P,� SIZE �S70RIE5 fAMILIES � ONE . . • : .� . . . . �... � � � - � � VALUATtON � Confroctor� THE �D'� GROUPpp�e�7I$IB�� DESCRIPTIONUF WORK� • .NEW ADo S 7,HO9 , , ❑I 6m exempt under Sec � � � � �G � 18 � F� � . ALTER B.&P.C.for this reason SLAB ONLY ` �PA�R Q ; =d 7 7,b� USE OF DEMOI . Date: . .. EXISTING BLOG. - � ❑ {`,�°`a e.s °' �. Signafure ' � APPLICANT � ' � TEL.�.. ... . . FINAI e OWNER-BUiLDER DECLARATION � PRiNT N�' . � DflTE � � �� � � r�r 5 I hereby affirm that I am ezempt from the Contractpr's License - � � ' - �s �w for ihe�foliowing��.reason(Sedion 7031.5, Business and A�DRES Sc141E 3S HbOve :� p�Nq�� °' �-°71E,2 J o ;ifessions Code): � PR � � � � ' � � BY � �0�,� �"8/ .,� BUILDING , I, as owner of ihe property, or my employeas with aDDRESS -wagas ds ihair sole compensation,will do the work and �OCAI�TY � , the slructure is not intended or offered for sole(Section � ' 704a,Bosiness and Professiona Code). n�toviNG , iE�. •' � I,as owner of 1he properfy,am exclusively conlracfing CONTRACTOR � NO. . ' � � � �with licensad conhactors to conslrV[f Ihe projetl�(Sec- qD�RE55 - � � � � �tion 7044,Business and Professions Code). � � CONSTRUCTIONLENDINGAGENCY -� :-�7�gp�K - YARD -HWY � .TOTAPRQPAINE�-"�' WI TH I hereby affirm thm ihere is a tonstruction lending agenCy for FRONT� � � the per4ormance of the work for.which�fhis permit Is issued P,L (Sec.309�,Civ.C.). SIDF � Citibank P'�' �Lander's Name . . . . . . � $ 444 S. Flower, L.A. 9OOJ�- P.G Fee S Permit Fee 63.75 �DMA Ref.fl lender's Add�ess ... �. � , ; 10.5 0 Lonw,Pic a g I certify that I h va read ihis applimfion and state fhct fhe . Issoance Fee 0 abova inform is mrrecf.I ogree lo comply with all County ��,resry9a}ion Fea � q ordinan[e n State laws relotlng to bullding consfrutlion, Toml.Fee... 7 Q..Z 5 LDMA Perm.8 _.. �$ an� lier y thorize representatives of this County fo�enter - �- - . mu t e• ' ned propeny for inspaction urposes. . - ' ' � � -�"�� � �- �� ���- �� �� ,� . �/ /� ... . . ... ..... ._. . . .... ..... . . . . . . .. .. . . . . � Q b SEE REVERSE FOR E%PLANATORY LANGUAGE - _ Signature of Appii�anf or Aganf DatB �� PiAftii Fv.�a?'P:i�d',P#7 � � dPa��'E:TOR'��?e�5 . C3Gt',"af€2 d �i[.Ut: )F(.C,Altl 4)!V .,-�,- . . . . i ,nt,Y lf h, i a �.�t f�. ':or c•�'6 . .... .. - , .,._.. ..n .�. � »., . , . ' .., . .+ . ' M .. . .', , � �Y�.; '., '.. ... Rs4Urnv*eE -�...�.' . �� -. ., . ;. -.. . . .' ' .. ' _.._._..—,�.,._ .At�Crarefl �--.--�_..�....._.... — T� r.J�F f s .�{ �j . r ry r � t (�D � �O � � [�G4C ':. . 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