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HomeMy WebLinkAbout1068A 1069A (5) _. .... ... _. „ ' �� WORKERS'COMPENSATION DECIARATION � � � � -. � � I here6y offirm Ihot I hove o�e�„f��a�e of�a�,e�„o,e�f � � � APPLICATIQN FOR BUILDING PERMIT . � insure,or a certificaie of Worke�s'Compensatlon Insurante, o�a certified topy thereaf(Sec.3800,Lab.C.) '- -- 31�A OUNTY OF LOS ANGELES BUILDING AND$AFETY PoiicyNo. 73wc005-2��]��Q16 NATIONWIDE ❑ PY� �' FOR APPLICANT TO FILL IN ADORESS 601 S. Junewood Place Cerfified to is here iurnished. � Gertified copy Is filed with iha county building tnspeo- eun�wG , liondeparlmenl.� ` ADDRE55 601 S. Junewood Place Dote 6-30-87 qpplicont THE ANDEN GROUP crtv DIAMOND BAR ziv tocn�m' D 0 D A � CERTIFICATE OF EXEMPTION FROM WORKERS' � � - � NO.OF BLDGS:�� � � NE4REST . COMPENSATION INSURANCE - � � SRE OF tOT NOW ON LOT CRO55 ST. (This seUion need not be completed if ihe permit is for one - � TRACT 43435 � e�ocK - ior r,o. "uEuoR � - hundred dollars(5700)or less.) � 7dAP BOOK PAGE PARGEL TEL. OWNFR THE ANDEN GROUP-� �No. 967— 41 ���"� "V'P S � I certify thaf�In the performonce of Ihe work for which this NO. � ��J� parmil is Issued,1 shall not employ any person tn ony monner ADDRESS-P.�. BOX 3329 O �1 S7ECIAL . . . � — so as fo become subjecl to 1he Workeri Compensatlon Laws. ���� O�v CONDITIONS 0 cm COVINA nv 1 2 U Date Appticant ' � ARCNRECT OR TEL. NOTICE TO APPIICANT: If, after making�lhf3 CertiEicate of DiSTRICT GROUP �NST �,f1 20NE PROCESSEDBY O Exemptlon, you should become subject to �he Wo�keri ENGINEER DAVE SZANY AIA r,o. 445-4073 `{mpensatian provisions o(the Lobor Code,you musl forth- ADDRE55 . . u 7`� 1`� W � ,lih comply with such prov(sions or this,permit shall be � O..' deemed revoked. � � � TE�• STATiS iG4�CuSsiFl nnON AFT. ONDO. (n corvTRncroa THE ANDEN GROUP NO. �I Z LICENSED CONTRACTORS DECLARATION���� �� � � . ii�,� �Qa55 NO. 'DWEu:UNitS�,L '� � � - I hereby ofii�m thef I om I�censed under provistons of Choprer 9 ADDRE55 AS ABOVE n,o. 510560 ��R�P (commancfng with Section 7000)of Dfvislon 3 of the Busineu and . . LIC.� � Profezsions Code,ond my license is In full force and effect. CITY M55 BK � � VALIDATION 510560 B s°e"� 1786 STOR�S 1 FAM�LOIES 1 CONE LieenseNumber LIc.Class � � � - � � VAIUATION eo��roero� THE ANDEN GROUP G-3O—H� DESCRIPTIONOFWORK N�- oe�a Apo � s 89,000 , ❑1 em exempt undar Sec. GARAGE 445 SF Air�R ❑ 8.8P.C.for lhis reasan Ools: � USE Of REPAIR ❑ � f 8O, 1!lt�. �1 D 6 8 A EXISTING 8t�("i. DEMIX ❑ Stgnolure . - . . . � � APRiGtNT iEL. FINAL �e • • o Q�j . OWNER-BUIL�ER DECIARATION 7RINT THE A N�• . DATE j���' . � I •�.1 p,5 5 I hereby affirm�hal I am exempt(rom the Contractor's License AD�RESS AS ABOVE FINAL � • _ Law tor�he following reason�Section 7031.5,Business and •4 1 Q 5 5 c� Pro�essions Code): � . . .. BU IDING ey O R 2�J�8 7 � I, as owner of the property, or my employea�with ADDRE55 � � wagee as fheir sole compensatlon,wiil do the work end LOCAti7V `� ��'9� 1ha strutture is not iManded or oifered for sale(Secrion -704d,Business and Professtons Code). MOVtNG -� TEI: - � � M. . • . •� � CONTRACTOR NO. . . I,os owner of Iha property,am axclusively contracting � �D with�Icensed contracton ro tonstruct Ihe projeet�Seo -�--- � -- - � � � � � � :�_ • � I ��i�5 Z 5 0 ADDRESS � tion 7044,Business and Piofessions Code). � :i ' � �; CONSTRl1CTI0N LENDING AGENCY SET�BACK YARD HWY T�TApROP.LWE WIDTH �- - "' , � l � I � '�t 5 7.5 0 u � I hereby affirm Ihof thera is o mnshuction lending ogancy for FRONT � � � . �• iha performance o(the work fvr whith fhis permil is issved �V.L . .. _ O E'2 6�a 7 (Set.3097,Civ.C.). SIDE CITIBANK P'�' Lender's Nama . . .- .,,.i . , l i'.� ? LDMA Ref.N lander's Address 444 S. FLOWER LA 90071 "�c F°°s �, v«m;�r�, - 447.�� � �i I canify thot I have reod IhiS applimrion and sfine Ihm the �O�UJ Issuance Fee 10•50 IDMA P/C M . , - above informotion is rrect.I ogree to comply with all Co�nry Investigorion Fee ordinontes and t laws relo�ing ta building conslructlon. , . . 457.5� To�ol Fee IDhW Perm.M � and heroby a or' represen�oiives of this County to eMer " � ' uponthea v ro errytor�nspectionpurposes. I,pM11 $75 . .$35 �� . � , ��I(�' . .��.'����''f�' �''i ��Z SFF REVFRSE FOR FXPIANATORY IANGUAGE , - � � � � � SignaWre of Applicanl or Agmt � �Dme -- -� -� - - � - � � , ' a . ,� - o 0 < ... l-. �. .�, -c� " �� .� � U+ '+'19 1D: O � p �� - b O OD • j � OI C .� :T ;� .. . ' n 7 m T N O ry �n = � �O �^ �' � � � '� ,p`.�� .. -,� n S a p ; � 6. .-ci c'� � 9 - C» Q y o "" ro � ' O � oo _ � 3 a cg D o ��'` o .. 1^ c: o :u O C i �v �� (9 O �`] .'9 ry 9��. O O �'y � � ': p f,. 1 A .. O : n � K C•' ,� 7 J P�1 O O n V �p � � .M �� .. 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