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HomeMy WebLinkAbout1538A 1539A (9) WORKERS'COMPENSATION DECLARATION � ' � � � � � I hereby a�f,�m ,�a;,��o�a o ceriificate oF consenl lo,e�f � -A P P L I CATI O N FO R B U I LD I N G P E RMIT insure,or a cenifim�e o(Workers'Compensarion Insoronce, � . or a certif'ed copy thereof(Sec.3800,Lab.C.� � � � � � - � � � 73wc005-2 p 6 NATIONWIDE 61 B 2 Car COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. �6m�� , , � Certified copy a hereby(umi:hed. � FOR APPLICANT TO FILL IN ADORE55 238�+3 E. Goldrush Drive � Certified copy is filed wifh ihe counly building inspeo �� BUILDING � - tion departmen�: ' � � � nooRe55 23843 E. Goldrush Drive oa�e6-30-87 qpp�;�a„�THE ANDEN GROIIP arv DIAMOND BAR zia41765 iocaurr DIAMOND BAR � CERTIFICATE OF EXEMPTION FROM WORKERS' '-- size oF ioT � � - n�iow oN�ior� � caoss srDIAMOND BAR BLVD: + GOLDEN SPRINGS � � �� COMPENSATION INSURANCE �� � . (This sec�ion need nof be complated i(tha pe�mi�is for one � . ASSESSOR - hundred doilars(5100)or le:s.) rancr 43435 BLOCK LOT NO.21 M,ep gpq( PAGE VARCEt owNeaTHE;ANDEN GROUP No.967-9541 us ZONE rnea I certify that in the performance of the work for which this ��� k_l NO. �7' permit is issued,I shall not employ any person in any mannar � SPECiA� so os to becoma subject to the Workeri Compensation Laws. � ADDrtESSP.O. BOX 3329 (� CONDITION$ � � . ... . . . . . U. Dote Applicant �in'COVINA zir 91722 ARCHITECT OR TEL. � NDTICE TO APPLICANT: If, after mokin �this Certilitole of DISTRICi GROUP NPE FIRE �ROCESSEDBY 9 eN�weea DAVE SZANY AIA n,o.445-4073 0 �emption, you should becoma subjecf to�tha Workers' � CONS '+1 �.q � U �ompenw�ion provisions of the Lobor Code,yoV mVSf{ofifl- qDDRE55 �v �-3 ��1� �.V W with comply with such,pravisions or ihis permit shall be . TEL �-� - Sinn57iCat MS�IF�CATION � AP7. � CONDp. N daemed ravokad. coNrencTorTHE ANDEN GROUP nto. �( � LICENSED CONTRACTORS DECLARATION.., QASS NO. �Jr� DWELL UNI75JJ� ? UC. - I hereby offirm fhat 1 am litensed under p�ovisions of Chapter 9 ADDRESSEI$��(�$Q�l$ ti0.51 Q5(Q (commenring w�rh Section 7000)of Division 3 of rhe Bosiness ond ��� �F�R M1�/+P Professions Code,and my license is in fuil force and effect � ' GTY �� � � - ��ta55 � �BK � � VALIDATION � r� Sq.F7. NO.OF NO.OF CHECK Li[ensBNumbel'lOS6O � �iC.CI05S$ - SIZE' 263�i ' STORIESZ ' ' {qµIlIES 1 � ONE '� . Comracro�THE ANDEN GROUP' Data � 6-30-87 DESCRIGTION OF WORK N�y � VA�UATION 2 ADD s 157,000 � 1 5 3 8 A ❑I om exempi under Sec. GARAGE 445 SF ALTER ❑ ,: �• • • •2� 8.8P.C.for fhis reoson � REPAtR � s Do18: ExISi�ING BLDG. DE/,�p� ❑ ) �4 1 fl 5 9 5tqnorore ' avaieaNt Tei. • �L 1 3 5 9� OWNER-BUILDER�DECLARAtION PRINT THE ANDEN NO. FINAL DATE �"�-g' � 09.� � �S7 .1 hereby offirm ihat I om exempt from the Comracror i License �� - ,yDoaess AS ABOVE Low for Iha following reason(Saction 7031.5,Bvsiness and � FINAL � � � Professions Coda)r .. ... . .-.. . -- . .- , _ . . . . . Ey . . . � BUILDING : � I, as owner af Ihe properfy, or my employees with ADDRE55 �� 5�9 A' � wo9esosiheirsolecompenmtion,willdotheworkand � ��- : � � �� � � �- -� � - �� � - � � �he structure is not intended ar offered for sale(Section LOCo.tiiv � ,� , -7044,Business ond Professions Code).�� � � - - MOVwG �� � �- � �TEL �- -� - � -. .j�• • e • •� � I,os owner of Iha praperiy,om ezclvsively conlracling CONTRAROR NO. - wi�h licensed contrac�ors to conslrvct the project(Saa � - � - �� ' . . _ . .I •6 7��Q tion 7044,Business end Professians Coda). - ADDRESS - ��- ,- ��� . �� CONSTRUCTION LENDING AGENCY - �- . RE uiREU YARD HWY- T�TA�SE 8 . ���,,j��`• �`� �� " � •��b�S O O.�.=i SET BACK PROP.LINE 'WIDTH - ' - I hareby offirm that thera is a construction lending ogency for FRONr � � � 0 9,1 1 �8 7 Ihe perfvrmance of the work for whicb this permit Is issued a.l. ' - � � (See.3097.Civ.C1• : SiDE . .. . . . . . . CITIBANK _ v.i. tender i Nome ' ' -- - : .`�; - - � -� - � � v.c.Fa.S 418.59 rermn rss 664.50 1°''�^R°f.K ` lender'sAddress 444 S. FLOWER. LA'90071 10.50 � � � I certify that I have read thia appllcotion and:tate that the, , �xi�on<s Fee IDMA PiC M , obava informotl [Orred.I ogree to mmply wilh oll Counry Investiqarion Fee � � $ ordinances a St e laws ralating to building canetruction, To+al Fee. 675.00 �LDMA Germ.N ond hereb ut rize ropresematives of this County to enter - � � � upo -m ' ed proparty for inspac!ti,o purposes. � $75 - $35 �� - �� � - - . - .. . ,. __ � V I� ' SE8 REVERSB FOR EX�IANATORY UNGUAG! ' . Siqnawre of Applicont or ApeN . ..po�e. .. . . .. . .. . . _ . . . . .___. .�� ---__ -� --- � 1•:��� . �\\:, . k ..._ _ _ . .. �._� r�ti.-- ._� , ... �..:� ..._ . .... . �,�-i , . . ,�. .. .._�.... i....._ � ,. . , ,.�,.,_...�. _ . .. ... . „i,k:•:r..._ .. . . . .. , . ._ . .- .. �.... ...`` . .,.. .. �, . ,..�.e :u, .. . 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