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HomeMy WebLinkAbout1566A 1567A . __ _ _ _ WORKER$'COMPENSATION DECLARATION � �. � �� � � � insure6or�oicertiica}reofWorken'�Compensation��;�.o��e' � � � �APPLICATI4N ��...FOR BUILDING�-PERMIT � � . o�a cerri�ed copy ihereof(Sec.3600,La6.C.) " COUNTY OF LOS ANGELES BUILDING AND SAFETY Pou�yNo.73wc005-2��fi�p,�6 NATION4IIDE ' • � Ceni(ied copy�s hereby furnished. POR APPLICANT TO FILL IN ADDRE55 23827 E. Goldrush Dz'3ve � Certified�mpy is�filed with Ihe covnly build�ag Inspec- �� gU1lDING � � • tion departmenl. ADORE55 23827 E. Goldrush Drive Daleb-3O—H7 Applitanf THE ANDEN GROUP C�Tv DTAMOND BAR ziv91765 '' �ocnuTr DIAMOND BAR CERTIFICATE OF EXEMP710N FROM WORKERS' � � - - - � - - NO.OF etDGs. � �� NEnReSi � � COMPENSATION INSURANCE�� � .. SRE OF l0T Now oN tot � caoss sTDIAMOND BAR BLVD. + GOLD6N SPRINGS (ihis saetion need not be completed if ihe permit h for one - TRACt�V3�+35 0�0[K l0T NO.1�9 MqV OOK PAGE PARCEL hundred dollars(5100)or leis.) � . . TE� I certify�ha�-in Ihe performonce of�fha work for wh�th this aW"E°THE ANDEN GRUUP n,o.967-9541 - ���IE OP ��'Ji�.C�� permit is issoed,I shall not employ any person in ony monner , SaeGql � AD�RESSP.O.�BOX 3329 Do d� CONOITIONS so as to become subject to the Workers'Compensa�ion Lows. � Dare npplrcam ntv COVINA ziv 91722 /''��O710E TO APPLICANT: If, afler making-Ihis Cartificole of ARCHrtECiOR tE�- DISTRICT GROUP ttPE FlRE PROCESSED BY O i :emptio�, yoo shoold bemme subject to the Wofkers' � ENGINEER DAVE SZANY AIA No.445-4073 � ,/� �p�T� � �ompensatian provisiona of ihe labor Code,yov must forih- � ADDRE55 �� 1�� � W wl�h comply w rh such provis�ons or this pCrinil shall be .. � � TEL , SiATISTICAL CIASS�FICATION �� A7T. ONDp. (ap� deemed ra�oked. , con�tuAcro$FiE ANDEN GROUP rao. n-., IICENSE�GONTRACTORS DECLARATION �� - . .-. .._ CUt55 N0." �V v DwELL.UNitS �, Z iic. I hereby affirm thot I am licensed under provisions of Chapter 9 ADDRESSAS ABOVE No.510560- ��R maP. (commenting wi�h Section 7000)of Division 3 af the Business ond . , _ �i�. Professions Code,and my license is in full{orce ond eNect. U7Y M55 - BK �� � �VALIDATION ' ' � 50.FT. NO.OF NO.OF CNECK LiCenSB NUmbe�10560 ���.��agy$ -' � " SRE 1658�- sroaies 2 � - FAMIlIES 1� ONE � . .. I NEW .� VALUATIOH _ ContractorTHE ANDEN GROUP Date 6-30-87 oescaici�oN oF woaK �p : 100,000 :� 5 6 b A ❑I am exempt under Sea GARAGE 456 SF , - � ALTER . ��• • •'�� B.BP.C.for this reusan - �� REPAIR ❑ �s � � oare: use oF oerno� I °3 1 6 8 4 �E%ISTING BLDC. - Signature AP�PR M 'j$E pjp � FINA1 y � °3 1 6,8 4� � OWNER-BUILDERDECIARAT�ON .DATE �'S�Q� . . I hereby affirm ihot I om exempt from the ControUor'a Litense nboae55 AS ABOVE � FINAL � O�.' 1�`8 7 Low tor the tollowing reason(Secrion 7031.5, Business ond �� � Professions Code): . . . . .. �-. -..--� - k N dY. � . . � BUIIDING . 1, cs owner of Ihe property, or my employees wilh ADDRE55 wages as their sole compensation,will do the work pnd - " � �� 5 Q,�A the struaure Is not in�ended or offered for sole�Section i�`��T� � 70dd.Business ond Protessions Code). � �� � � MOVING � TEL. � � � � - � � I,as owner of the property,am eaclusively controcting CONTRACTOR NO. � ����� • • • � . with licensed contracton to comtruct tha project(Sec---�� � qooaess �� � �' � � � - � � I •�rJ�7�Q� tion 7044,Business ond Proiessions CodeJ. �.�-,� (\ ,j , - CONSTRUCiION LENDING AGENCY - � SEt�BnCK YARD HWY TQTApROP.lME Wi07H � � f �� � • •J C Z O Q u I hereby affirm that�here is o construclion landing agency far FRONi �� � �he performonca of the work lor which this permi�is iesued — � 7.�. � , � ' ' � � - ' O 9.���--fj 7 (Sec.3097,Civ.C.). SiDE � - CITIBANK v.� ' ...1;- Lender's Name - .. '� , � P.C.fee S 316.8A . P„mu Fe, .-4%�:50 ion.w aec• � �� . lender'a P,ddress 444 S. FLOWER. LA 90071 1 � , I certify that I have tead Ihis applitelian and sfate ihat ihe _ .. lasua�ce Fee IONA P/C N _ . . obove Iniormali Is corrett.I ogree to compiy with all Couny Invesr�gai�on Fee 50'�.00 . '' ordinances o tate laws ralating to build�ng con3lruclion, To�al Fea ' ID/M Perm.M - and herob a oriza reprosenrotives of this Gounty to eNer � upon th - ed property for inspaction urposes. �A $7c, . $35� SFE REVERSF i0�EXPIANATORY IANGU�GE .. Signoture Of APPIiCont or Apent �.�p1p " ' . . .. . . .. . . . . . . . � PlANS TO APPIICANT INSPECTOR'S NOTES .,�URTIiK•UUIf.Uh:R UIiCI.AHA�I'IU\ � I he�eby aHrm�hc�i 1 nm ezemp�hom the Con�roaor',r To: . , . � Rofumed ; '. � ' . ,. ' , 'licen.e,lo� � to �hc �lol�p 9 ieroso , (S. 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A� orals :..-� �.�Ro9uirod '. . .. .. �- -- ------'� ...:.�-�--�--� - - �-- ---.. _ � an�'�pfi��nt/or��permil.iuhjcrlclbeapplican��n�:iri! i,_ � - Data Recelvad.' � ' ' Pvr... -Yes No orApproved. . ..� . . " , � ,._... . �-^J'rn�lyn/nnfnrnrrlhun/nrhundreJJ��ll�r,(t5pp11� .: ��_."._ ..__._ . .,�._.____ � , ' ..._ _ . __:._ .�___._.....__-�. . _ . _ �: I,os owner of Ihe propeny.'o�my employc�•s w��h � . . ,._ . .. . . .,-. N'aier Ce.nf¢qie__. ._.:.� <-"l � i ....�� . _,_�... '": __ ._... ...._ ___ _. _. .-_. wdgr.s as Ihe/aole.compa sc�ion.wi 1 do rhe worL.nnd __.__ . ... `�.., i r I � - - � . ihe sirudu!e is not inicnded or oilered fo��sole(Sct,70��sj . ' PieolihdePonmeni'_ __. � .�.�. .� �. ., ._.-.'___- _ ._ _.-___..._ _.�. ._ _ '. ..._ . . _ . 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