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HomeMy WebLinkAbout0777A WORKERS'COMPENSATION DECLARATION � � ..; �- � � � -'� `�� � � J''� >. . � .. .. , . .`�. ..�. . ..,-.. ..� LJ I hereby affirm �hat I have.a certificaie of consent to self - AP�LICi4T1C�N ��FOR-���U�IL�31�IG PERMI�T � ��� insure,or a certificate of Workers'Compensa9ion Insurante, or a certified copy�hereof(Sec:3600;�ab.C.) COUNTY OF LOS ANGELES 8C]ILDING`AWD SAFETY aoi��y�Zo�C005-279���,y Nationwide 1 B � Certified copy is hereby furnished. . FOR A�PCICANT TO FI'LL!N aulto�Nc� � Certified co -is filed with.the covnt buildin in3 ec- � � � nDoke55 526. Dol2�CouYt PY� Y 9� p BUILDING iion departmenf. ADDRE55 5�26. Dole-Court . Date ���s�8� .,4pplimnr .THE�ANDEN GROUP. citr Dia.mon.d B�.Y Zip 91765 iocnu�v Diamond Sar CERTIFICATE OF EXEhAPTiON PRdM kVOftKERS' ��� � � NO.OF B�DGS. NEARESi .� � � - - COMPENSATION�INSURANCE -� � - SizEOF�Oi NOWON-LOT ��� - CROSSST. D12.1110I1CI S8Y B1vd./Golden $ Y'lri (This,section need nof be completed�if.ihe permii istor�one TRaGi 425-�9 �� BLOCK LOTNO.� $9 �ESSOR�" ' ' � . Mundred dollars($100)or�less.) - MAP BOOK� '� PAGE PARCEL TEI. I ceriify that in the-performance of ihe work for which-this OWNER � � Np: _ U�O�NE � oP p�J.� ,p ! `� permit is issued,I shai�not employ any person in any manner SPKIAL � �' . so as to become sobject fo 1he Workers'Compensafion��Lows. ADDRESS �� P.�a� BOX 3329 . � �C� C N�iTIONS � U �{:.�te � � Applicant :..: ��.� � � . . A�RCHITECTOR� � . ZIP TEL, � � _ . . ... � nOTICE TO APPLICANT: If, afrer making�this Certificate of � � � DISTRIQ GROUP NPE� �� FIRE ROCESSED BY Q exem ti0n, ENGINEER D'dV@ Szan AIA rvo. 445-4 73 p yoo should become sob�ecf to ihe Workers' � . / � COI�,ST. ZONE � I— Compenwtion provisioos of the lobor Code,you must forth- qDDRE55 314 N. First, Arcadi.a . 910�6. e d .�� � � W wi�h Comply wdh such provisions or this permit shall be - � � �.TEL, � STATISTICAL CLASSIFICA710N APT. ONDO. � . deemedrevoked. � CONTRACTOR -.� 1,� � (;. � NO. � LICENSED CONTRACTORS DECLARATION � ���,. � . Ra55 NO..�OWELL UNiTS —� I hereby offirm thoi l om-licensed under provisions of Chapfer 9 ADORE55 $3IliH 3$ above : . No. 510560' . (commencing with Section 7000)of DiviSion 3 of fhe$usiness 4nd ...__.. SEWER MAP �������������� UC. Professions Code,and my ticense�s in}ull force and effect. CI7v � �CLA55.- BK. �. VALIDATION SZOS6O $ sjQZEFT �'S3S S10R�5 Z AMILIES 1 CONEK License Number lia Class ' ' .... ' .. � VALUATION�'. . . � �a���o��o� THE ANDEN�GRQUPpa�a 7/8/87 DESCRIPTIONOFWORK � NEW s 7�$O9 ADD , ❑I am ezampt�nder Sea GSra 0 ^ 1 Q ALTER 8.8P.C.for lhis reason � . .. REPAIR ❑ Y � � � Date: USE OF � �EMOL . EXISTING BLDG: ❑ Signature . . .. APPUCRNT.. . .... ... .. . ifL�.� .. . . ..... fINAL � c�y PRINT THE D N�� P-. � Na. ...pATE �' OWNER-BUILDER DECLARATION -� - � - � - � �p �C? 1,7 R I hereby aHirm fhat i am exempl from the Controctor's License $3IR2 dS�SbOV2 �nw for ihe following reason(Section 703i.5, Business and AODRE55 FINAL - � ��.,.'a.e�e'o�� ��. ifessions�Code}:.. .. . . . .- .. . . . . . . . .... . . .. BY . BUILDING � � - j .a�''.�2 r� `� I, as owne�of �he proparty, ot my employees witb ADDRESS . �� .�� wages as their sole campensation,will da ibe wark and � .,, _ ,7��5� the structure is not intended or offered for sale(Section LOCALiiv � � ' � � . m-a� 7044,Business and Profeuions Code). MOVMG ' TEL. Q�� ,���7 � I,as owner of fhe properly,am exclusively contracfing CONTRACTOR NQ . , , with licensed contraciors to ctinStrvcf the projeci(Sec- � ADDRESS � '� � tion 70-0d,Business and Professions Code). - �� � CONSTRUCTIONTENtlWGAGENCY -�-�"-�" ����-� SET�6ACK '- YARD HWV � TOTAPROPLINE�-' �� WIDtH I here6y affirm that lhere is o construction lending ogency 4or FRON7 -� the performance of rhe work far which this permit is�issued � �� a.l. (Sec.3097,Civ.C.). - SIDE Citibank °'�' , Lender's Name . . . 444 S. Flower, L:A: 90071 P.C.Fee$ Perm�tfee 63.75 �oN'°'Ref.# Lender's Address � - ' � I certify that I have read this applico�ion ond stqte.ihot ihe - . iuuonca Fae 3.�.5 Q LDMA PiC M above inform ion is correU.I agree ro comp ly with all Counry Inves+igaflon Fee � � ordinance Siate lows relating to building consfruction, . Tmal Fee �74.z"rJ LDMA Perm.# 0 and her y uthorize representatives�of this CouMy to enter a upon ntioned properiy for inspectio purposes. -�� � � � - �� - �� - ���� -� � �� � � -�' '� �� � � � ���� SEE REVERS�FOR EXPLANATORY LANGUAGE . ._. ..�, � . . . Signar�re of Appl�mnr or Ageni re - i PIR.Fd^ �'1��'�t&�,A°�Y � i@=SA��-'Jk'S P2CYe65 C)�1"v3 P2 7}(SI C E I2 IJI�.3 F �, i4)^. < - �Te� ���.. €Fetur� - �^ ..� ti i _ c .i . 7) ��. � F�p ovad � _ ..,_ -.----.--. 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