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HomeMy WebLinkAbout1568A 1569A _ . t�t z.5 Pc��c-�1.� s�ot oa5od5 WORKERS'COMPENSATION�ECLARATION . � : �� ' � I hereby affirm �ha,1 hove�a cerfiiica�e of�o�,e�<<o se�f �--� � -�- ,q�PpLICATION� FOR BUfLDING -PERMIT insure,or a certificate of Worke�i Compensation Insuronce, or o ce�trfied copy tfiereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY Po�icyNo.�3wc005-2�7��Q�16 NATIONWIDE 36 A � Certified copy is hereby fvrnished. � -� � -� -� FOR APPLICANT TO FILL IN AD�RE55 24020 E. Goldrush Drive � Ceatfied copy is filed with�he ceunry building in:pec• ��- BUi�DING Zk�2� E. Goldrush Drive � lion deparlment. ADDRESS Do�a 6-3O—H� Applican� THE ANDEN GROUP arv DIAMOND BAR ziP91765 iocaurv DIAMOND BAR - CERTIFICATE OF EXEMPTION FROM WORKERS � � � NO.OF BlDGS. . NfAREST COMPENSATION INSURANCE� - � SIZE OF LOT raow oN ioi caoss sTDIAMOND�SAR BLVD. + �GOLDEN SPRI (This sectian�eed not 6e compleled if Ihe permit is for one +45SESSOR hundred dollors(E100)or less.) TRn[i 4�435 eioCK LOE`NO.ZS MAP BOOK PAGE PARCEI owNeaTHE ANDEN GROUP No.967-9541 u zoNe �P �� �� I cerlify thof�io the perlormonce of ihe work for which Ihia �—� p permit is issued,I shall not employ any person in any manner . qDDRESS P.O. BOX 3329 v J SPECIAI . so as to 6ecome subjett lo Ihe Worker5'Compensarion lawS. �!� CONDITIONS � U arr COVINA ziv 91722 ' • � Oate Applicanl � ARCNITECT OR 7EL DISSRICT GRpU7 (YPf � FIRE �ROCESSED BY O �TICE TO APPtIUNT: If, after moking�this Certificote oi EnIGwFEa DAVE SZANY AIA r,o.445-4073 � ro T,��, p � �mption, yov should become su6jecl�to the Worke�s' �!CJ V l:ompensation provisions of the Labar Code,�yau must forrh- ADDRESS 1 �� •`'� �/ � pw.. with comply with such provisions or this permit shali be . � �-TEL.- ' ' � STATISTICALClASSIFI A710N AGT. ONDO. (n deemed revoked. eoNraneroaTHE ANDEN GROUP No. � � Z UCENSED CONTRACTORS DECLARATION � � LIC UASS NO. OWEIL.UNiiS I hereby afflrm Ihot I om licensed under provisions ot Chapter 9 AOORESSAS ABOVE No.510560 SEv1ER MAP� (commencing with Section 7000)of Division 3 oi the Busineu and , __ . LiC. , � Proless�ons Code,and my license is in full force and efieci. CitY CU55 eK � VALIDATION $Q.Fi. NO Of NO.OF CHECK LicenseNumber5lOSC)O �� �� ���.Class B � srze 1658 S10RIE5 2 vaMiucs 1 � � oNe uq� � THE ANDEN GROUP 6-30-87 oeseaia�ioN ov woaK I I DD a :A�Uu��� �� 5 b 8 A Contractor �ate �I om exempt under Sec. GARAGE 456 SF A�TER � , �• •+ •2� 6.8P.C.for this roason _ RfPAtR � s �., � •3 1 6 8 4 �- Date: USE oF E%ISTiNG BLDG. �'�'�� e = 5� naWre APPLICAM 7EL. FINAL �'3 1 Q 8 4� 9 OWNER•BUIlOER DECLARATION PRiNT THE ANDEN GROUP NO. DATE /'�9�� . c 9.1 1 —8 7 I hareby oiiirm that I am exampt from fha Contracfor's llcense � qpDaESS AS ABOVE FINAL � �,� �.�/ � � law for the following reason�Section 7031.5, Business and sY �/,j 1�//. Profes:ionsCode):� -� �� � " - � - - , ' �'s ���' �� � 8�����NG _. . . .. _ . , , �. I, as owner of 1he properry, or my employees wifh ADORESS wages as their sole compensaiion,will do the work and � , . �� 5 d 9 R the structure is nof iNended or oifered for sale(Sedion L�CAIITV 7044,Business artd Professions Codc). � � MovtNG - � •� '°��TE�. ''� ' � ' � �i� � • • •� 1,as owner of the properly,om excl�sively confracting CONTRACTOR NO. � with licensed canhactors lo conahocl the projett(Seo- qDDRE55 � �. r � I °5�7.�� �ion 704d,Bosiness and Professions Cade�. �---�' ` � � ��� t�-�' REOUIREO T01AL SE(6A K � � �' ' • a 5 G 7.0 0 u- - CONS7RUCTION IENDING AGENCY � 5Er encK YARD Hwv pRpp,��� wiorH - '_r��� I hereby affirm Ibal there is a conslruc�ion lending agency(or feONi � , �� Ihe performance of the work for which�his permit is issuad � - -P,L `� [�,_� •- �� '� O 9,� � "H rI (Sec.3097,Civ.C.). SiDE . . . . CITIBANK �.� �- ' lender'e Nome LDhV1 Ref.N �� +-�"� ,:,,`�� �� - � lendefs Addrcss 444 S.� FLOWER, LA 90071 � � � P-c.Fss s 316.84 P,,,„��Fsa .496.50 �, !�� � � � 10.50 I certify�hat I have read ihis opplica�ion and s�ata thm.the � ies�a�ce Fee �DNa G/C M ? obove informmion Is correct.I a9ree to comply with all CovnM �nve:ugaron Fee � . q ordinonces o ata laws relating to building conslruction. .. iotat Fee .r'��7.00 L�MA Verm.M � Q � and he�eb u oNze reprosanta�ives of�his Coumy�o emer a upon�h - ' ned properly for inspacr' n orposes. �� �..75 .. $3rJ . ' . . . ^ �,� SEE lfYERSE i011 E%�UNATORY UNGUAGE � I . . . Sfgnaeure oF Applkon�or AgeM - � Dota . . . . . . �. * , . � PlANS TO APPLICANT r �INSPECTOR'S NOTES .-UR'�\lill-RU11.Dh:K UI:l:1.AftA�I�IU\ ' . I f k y aff II c i I a np(-f o �ihp Con ..� ' To: �. �� :. ; � � Returned �.:: � APP��"' � . :� .� • . � ��� : � C , .. � � }c sF�lnw I itc�4oll�wi g� ,•no '(Sec��7031 � � �oved .� . . •�BitamcasarsJl r I scu�ns(ndi.Anyatt ir.��unft.ulrtrl� No. Dafe Na. .'.Uci¢ .. '_. .. .�.. • •. •• . . ..._ . ,� �. rryui •s�e J�rr»iif tu rnneln�rt,��eltrr.irnprn r.Jrnruli.�L, -- -._ �h unv�r� ih ��,h t� t.�ei� ����lsor�yu�u �� '.C - ' l.. +_ .. . ,��. . � - . . il� a hc�+nr :suJ� - . ..,.; . •. ,.'� ... ��•. ,�.' �"� ; ': �� � rur rn/i(�n u�nrd sratenrrnr ... 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