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HomeMy WebLinkAbout0797A (4) W6RKER$'j,DMPEN$ATION DECIARATION � � f� � I beroby o�L.m�ha�i ho�e a«,,.���e,�o<<a�,e�„o.��� APPLICATION FOR BUILDING PERMIT �� � insuro,o�a mni(icaie of Worken'Compenso�ion Insuronce, �,� or o eer�if�ed eopy�herea((Sec.3800,lob.C.) � - • �7o��Cr,�05-279—OOl�mP,,,y Nationwfde 2/B COUN7Y OF LOS ANGEIES BUILDING AND SAFETY � Cen+fted copy�s heroby lu.n�shee. FOR AGPLICANT TO FllL iN �DD�REA 24209 G0I11 P1dC2 � Certi6ed eopy fa/ifed wilh ehe counry building inspeo BURDiNG liendePonmeni. ADDRESS 24209 G0rt1 P1dCB po�e B—S—H� Applican� THE ANDEN GROUP arr no oc�uitr CFRTIFICATE Of E%EMPiION fROM WORKERS' S�ZE Oi�OT �ororB`io� cR�oss sT, Diamond�Bar Blvd & Golden Sprin s COMPENSATION INSURANCE " " ' (Tbis secfion nesd no�be completed if Ihe permit b for one fR�R 42580 g�p�K tOi NO 3 5 �E� � � hundred dollors(f100)or less.) , mAv EOpf vAGE o�RRI ov,,NFR TEIE ANDEN GROUP `� 967-9541 � zor+E ,� � 1 cern[y ihoi In�he pedo�mance o(Ihs work for which lhia � pe�mi�is hsued,1�holl no�employ ony person in any manner ��af� P•Q. BOX 3329 Ud� Cp�pinp�5 � �o es eo become tubjec�to ihe Workera'Compenw�ion lows. O �Ye ApPlicont C�ry 2iP v .OTICE TO APPLICANT: 11, oher moking fhis CeHificate of ARCHITER O�+ Tf�� _ DiSTRiGi GI+Ouv rirE fiRE OCESSED BY O ENGINFFR �� CpN$T. 20NE U FKemplion, you thould become s�bjec� to Ihe Wo.ken' Compenwtion prorisions of Ihe Labw Code,you mus�fo.th- �ppqEu 1 1� Q�J� wilh comply with aVch D�Ovisions or Ihis permil sholl be 1E1. S�Ar15iIUl C�SSIFICAiION AVT. OkDO. (n deemed revoked. �Tpq�pp THE At3DEN GROUP � IICENSED CONiRACTORS DECIARATION p�, d�35 NO.��'�Q DwFtl.UwiS Z I hereby oN+rm elro�I am licenaed under provisions of Chapier 9 �DORE55 OV � NO. 51�560 ��R� (commencing wiih Section r(1W)of Division$of the Buslnessand �iC. - Pro�essionf Code,ord my licen»�s in lull Twce ond eHecl. CIiV CUSS B BK � VALIDATION 50.Fl. ry0.OF tq.OF CHECc t+canfe Nombe� 510560 ���.�lass B SRe 1314 STd+ifS Z �AMIL�FS oNc VALUATION A—S—A7 �3CRIOTIpNOFWQRK ''�`�`' Contrac�or TNF AN[�F.A7_GR(lIY$�e � f ( B2Q ❑1 om exemPt vnder Sec. i G8L8ge ` `�b 7 9•7 A AIRR �� �� • • � . B.d�.C.fo��hfs reaso� 1 RFPAIR s ��a i ••eaoo Do�e: F%iSnNG BtDG �'�'a , AiR1U,N7 lEl. •1 • $gnature �iNT FINAL b a(�0 c> �. OWNER•BUIIDER DE0.ARATION T � �� OATE �L'v � I hereby affirm that]am sxempt from�he Comrocbr'a license ' O ES� 7�8 7 �ow for the lollowinq reason(Section 7091.5,Businsa and A�QFSS FIHAL /� fe�siomCodel: � �� !!".,� Ja�,�o�� I, o+owner of the property, or my employves with ADDRE55 waqesos Iheir sote compenwiion,will do the work ond i�iiTM , . � � the��r�c��re ie no�Iniended or offe.ed for wle(Sec�iO� 7W1.Bus�ness ond�rofees�onS Code). MOvnvG iE�. � 1,os owner o(�he popenY,am aaclusively contractinq O�+iw�ROR NO with licensed controUon lo construc�Ihe projetl($ec- ,�ppRF55 tion 7W1,Business ond Profeesions Code). CONSiRUCT10N IENDING AGENCV SEPB�C� YARD MWY ���ApR�jWE wiorH � 1 hereby o1firM Iho�ihe�s h o con3nvcNon lend�ny aqeney(or f aONt IAa pe.fwmones e(the work lo�whieh Ihis permi�is issuad v e. ($ee.�097,Civ.C.). SiDE ei. lender'sNome Citibank IDMA Re�.I � 444 S. Flower, L.A: 90071 °C °'°s °«'""�'" , la�der's Address 10.5 0 � I esn�fy�he�I havs raod Ihis appllcation and sroie�ha��he , i,.�,e�c.�« �D�P�C� � abova infa ' n b carxL I oqree ro comply wiih oll Counfy �„w•��qo��on F« 6 8.0 0 $ wdinonees n Siate laws rola�infl to bWldinQ eomvuction, �ob�p.� miw�,ve.m.J R and her y ihorizs rep�esematives of�hi�Counry to�nter � upOn t G ntioned poperty for Inspection purppses. � � fEE�FVERS[�OII[7(HANATOIIY UNGUAG[ � S�qnerw�e�Appi�can�v Aq�n� Do�e � PlANS TO APPUCANY INSPECTOR'S NQTES ,��.�7����Ft�kt(,'41.1)I�.H ULI.I,:\HA I IU� i Fr,rbr a �•i�-�a•i n � � .r Cn.;�•;ra;,�s . . . :�a. t.la �� 1 . r 1-. rC�•c•T)�1� ' To' . . � . . � � YIWuTed.1... . -�. . ' . " � ! . � !.r y. ' , , . ., . � < < � �� �ADGrovod Hu. ��n:l l r 1� � n ( .d� �ln�ilrt� •�wnh ul�i.L �Nn. Do� Na��'Aarc . .. • } • .. ` .' • , . '. ••_ .��C rrq �.a�J frrn il l.�<.�n�fru�l,uliu,� J .J�.vnlnF. _.___.____�'_..- . _ ..._.__. _'.... .___._____ - � r,�rl,......r yl.�.r�y.�e . "_ . 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