HomeMy WebLinkAbout1070A 1071A . ' ^ WORKERS'COMPENSATION DECLARATION � �- - n
I hereby affirm tho�I hove a�e,,;f;�a,e of consent to self APPLICATION� FOR BUILDING PERMIT '� �
insvre,or o cerrificote of Workers'Compensation Insurance, ��
or o terlilied mpy thereaf(Sec.3600,La6.C.) � : (�]_�(', . - -
Poi�� Na. 73wc005—�d��R�16 NATIONWIDE ��UN Y OF LOS ANGELES BUILD�NG AND SAFETY
Y (MODEL Plan a
❑ � � ADDRESS 600 S. Junewood Place
Certified copy is hereby fvrnished. FOR APPLICANT TO FILL IN
� Certified topy is filed wilh Ihe county building inspec- � BUILDiNG 6�� S. Junewood Place � �
lion department. AODRESS
Dme 6-30-87 Applicam THE ANDEN GROUP citt DIAMOND BAR ZiP 91765 iocAutt DIAMOND BAR
� � CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF lOT NOW ON�LOTS CROS555T. DI
� COMPENSATION INSURANCE�� �
(This se[fion need not be completed if the permil Is for one . ASSESSOR
hundred dollars(EI00)or less.) . TRACT 43435 BLOCK LOT NO. 54 MqP BOOK PAGE PARGEL
TEt. USfry20/E NOP � I '� 5
OWNER THE ANDEN GROUP �No. 967-9541
I certify�hat�in the performonce of the work fo�which this OL �
permit is issued,I shall nol employ any parsvn in any manner qooRE55�P.O. BOX 3329- SPEO'4L . _
so as to 6ecome subjett lo Ihe Warkers'Compensofion Laws. ���� CONDITIONS" 0
cm COVINA ziP 91722 v
Data Applicant �
ARCHITEGT OR iEL. DISTRICT GROUP TY7E FIRE PROCESSED BY
NOTICE TO APPLICANT: If, afler moking�fhis Ceniftcale af ENGiNEER DAVE SZANY AIA r,o. 445-4073 CONST. ZO U
.Fxemption, you should become su6�ect 10,the Workers'
�mpansolion pravisions of the Labor Code,yo�musf forlh- AD�eE55 314 �O �� �� � w
ih comply with such provisions or this pe�mit shall ba . N
deemed revoked. TE�� STnnsncat cv+55iricnnoN APT. CONDO.
mNrancroR THE ANDEN GROUP No. .�I Z
LICENSED CONTRACTORS DECLARATION - pC. -C I a S S N O. � D W E L L U Ni T 5 1 L� �
I here6y affirm tha�I am licensed under provisions of Chapter 9 ADDRE55 AS ABOVE No. 510560
(commencing wiih Section 7000)of Division 3 0(tha Business and ��� SEWER MAP
Professions Code,ond my license is in f�ll forte ond eHec�. CiiY M55 gK � � VALICATION
510560 •B s°eFT' 2634 s"TOR°s 2 F MIL�IES 1 CONEK
ticenza Number lic.Class
VALUATION �
THE ANDEN GROUP G-3O—HJ DESCRIPTIONOFWORK SIN LE
NEW
Contractor Date ADD � S 157�000
❑I am exempt under Sec. GARAGE 649 SF qtiER ❑ ,
6,8P.C,for this reoson RE7AiR � s�If.� �� �� 0�,�R ;
� Date: EX ST�iNG BtDG. DEMOI ❑ r � #• • • •2 3
� Signature � � APPLICRNT � � ' TEL FINAL I •5 9 7.9 8
OWNER-BUILOER DECLARATION , PRiM THE ANDEN GROUP N0� DATE
1 here6y affirm that I am exempt from tha Contratlor's license --� l'lc~� - • a S�j�'��;
Law for the following reoson�Section 7031.5,Business and NDORE55 AS ABOVE FINAL
Pro�essionS Cod��: ' PRESENT -- -� - 6y 0&2 6—8 7
QBUILDING
I, as owner oi the property, ar my employees with ADDRESS =� C 7.� A
�� woges as their sols mmpensation,will do the work and ���n, � -� - - - , - �
the strodure is not intended or ofiered For sale(Seclion �s � � � � � �
7044,8usiness and Professions Code). MOVING � - TEt. � --
� I,as owner oF fhe properly,om e.dwivaly conlracting CONiRnttOR NO. , , �.., � •6 7 ra O,O
with litensed conhattors ro tonstrucl the projetf(Sec- qDDRE55 � � � �� � , r
tion 7044,Business ond Professions Code�. . . � ' " '��J.Q n�
REOUIFED TOTAL SET6AIX R M XI
CONSTRUCTION IENDING AGENCY SET BACK �YARD HWY PROP.LINE WIDTH - �, ,' � ��� � � O E.2�]�II 7
I hereby af{irm thollhera is a conilruction lending agenty for FRONi . � f .� � 1� , ,
Ihe periormnnce of Ihe work ior which fhis pe�mit is iss�ed �P.l. � `, � �
(Sec.3097,Civ.C.). SIDE � �
CITIBANK °.�. ' . ' .
lender's Nome ..� IDMA Raf.M � - �
lender's Address
444 S. FLOWER� LA 90071 P.C.Fee f HZD.7`3 Permit Fee 664.50 ;
1 certify thm I have read ihis application and state that the . _ . S �asuance Fee Z�.�J� IDMA P/C M '
obove information is correcf.I agrea 10 comply wilh all Counry imesngar�on Fee
ordinances and e laws telatiag to bvilding Constr�Uion, . Total Fee 675.�� IDMA Perm.M � f�.
ond hereby h te ropreeentotives of this Coumy�o emer �� .
upon�he ov e ed propeny for Inspectlon purposas. �� $75 $35 '�
� p I, ! � i'.-�. :
SFF REVEKE FOR F%/UNATORY IANGUAGE /
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