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HomeMy WebLinkAbout1072 1073A (5) , ' ^ WORKERS'COMPENSATION DECLARATION _ . . " � - � � � �- � - ' " -� - ' " � � insureborafceriiita'teofWorken''Compensaton��;�,a�«' ��APPLICATION FOR BUILDING PERMIT . \ or a cemiied copy�heroof(Sec.3eoo,tob.C.� - 75/A �OUNTY OF LOS ANGELES BUILDING AND SAPETY aoi�cyNo. �3wc005—�a�P��16 NATIONWIDE (MODEL Plan Cenified to s hereb (ornished.� BUIIDING ❑ PY' Y FOR APPLICANT TO FILL IN ADDRE55 604 S. Junewood Place �� Ceruited copy is Filed with the coonry building�inipec- ' eunoiNG tlondepartmenf.� ADDRESS 604 S. Junewood Place . Da�e 6-3O—H� ApplkaM THE ANDEN GROUP c�1v DIAMOND BAR zir 91765 �ocnurv DIAMOND BAR CERTIFICATE OF EXEMPTION FROM WORKERS' � � � � � NO.OF BLDGS. � � NEAREST . � � COMPENSATION INSURANCE - SRE OF LOT NOW ON lOT caoss sr.DIAMOND BAR BLVD. +�GOLDEN �This sactlon need nof be tompleled if tha parmft Is fer ona - . ASSESSOR . hundred dollars(E100)or less.) -� . TRACT 43435� � e[ocK l0T NO. 55 Mqp gpq��� PAGE PARCEI owNea THE ANDEN GROUP TE�' u oNE �P No. 967-9541 I certify rhar in tha periormonta of the work for which�thie _� No. �7�.3 q � permit is issued,I shall no�employ uny person in ony manner SVECial . . . - . _ so as�0 6ecome subject to the Workers'Compensation Lows. aooaess P.O. BOX 3329 - f40��eor,o�rioNs o cirr COVINA zir 91722 - v DotB � APpii�o�t ARCHI7ECi OR TEL - � NOTICE TO APP�ICANi: I(, a(fer making�thi3 Cerlificate oI DAVE SZANY AIA OISTRICT GROUP TYPE FIRE VROCESSEDBY ENGINEER r,o. 445-4073 0 _Eaemption, you should becoma wbject to tha�Wmkers' �� � Q CONST. ZO�q �—. ' �mpensation provisions of�he lobor Code,you must forth• AD�RESS 314 N. FIR .�� f�3 � V w A1h COmpry Wi}h Suth proviSions Of fflh permil ehall ba ' 7Et SiATI5T1�P.lQA551FICATION APT. ONDp, � deamed revoked. �pNTRAROR THE ANDEN GROUP No. .►—/ UCENSED CONTRACTORS DEQARATION��� �' � � -. . � ��� . c1n55 No. " ���owEu:uNiis_LL � Z. I hereby oHi�m the�I am licensed vnder provisions of Chopter 9 ADDRE55 AS ABOVE No. 510560 �� (commencing wiih Setlion 7000)of Division 3 of ihe Busineu and . .. _ . . . ���,_ . SE�`'ER MAP . � Professiom Code,and my license is In full forca and eHect. CITY C1A55 � ��BK - � � � VALIDATION • � SQ.FT. NO Of NO.OF CHECK LicenseNumber 510560 ii���o,=� B��- - - sze 2�74-STORIES �Z�� FAMILIES �1� � ONE - VALUATION � THE ANDEN GROUP G�3O-S� DESCR�VTIONOFWORK SINGLE ILY ^'� ,. Controc�or Data App � s 164�000 , �� �� �I cm ezempt vnder Sec: GARAGE 643 SF _ . ❑ Z� • AITER B.BP.C,for thfs reason REPA�R ❑ - s [� � ( . .... . . . . USE OF - l�J /�I Date: ... . � E%iSTiNG BLDG. DFMOL ❑ - (o/S'.Q3 >, $ignotore APRICANT TEL. FINAL ' � OWNER-BUIIDER DECLARATION PRINT THE ANDEN GROUP NO. � � - - DATE� �—ZA�,� I hereby affirm that I am e�empt from the Contractor's license qDDRE55 � AS ABOVE ����`�7 Law far Ihe following reason(Settion 7031.5,8usiness and FINAL � � Professions Code): - �- - �� - � � � ' � � . gy' � � - . ❑ BUIIDING I, os owner oF the property, or my employees wirh ADDRESS � wages as thai�sole tompensallon,will do Ihe work and ���Ty S -- - � tha structure is not intended or offered for svle(Settion 7044,Business ond Professtons CodeJ. MOvtNG- TEI.�� �� � I,as owner of Iha property,am exclusi�ely conlratfing CON7RAC70R NO. with licensed comrauors fo constroct iha pro�ect(Sec- -� qo�ae55 '-1'��� � � tion 7044,Business and Professlone Code). . � � I REQUIREO TOTAL SEi6AIX _! • '•5' '(� � . CONSTRUCTION IENDING AGENCY � SET BnCK �AR� HWY PROv.tinlE WiDTH . ' � �' !� - � - 1 he�eby oi{irm that thera is a conshutlion lendin9 agency(or FRONT �`�; '. ' `' O 71 3 A ��ha performance oi the work for which this permil is izsued p.L � � �- � . ($e[.3097.Civ.C.)• SIDE �� ,+�• • • • • � . P.l. . , ' .. ', .1 . IS K _ :_. , _ • 1•. lendar's Nama � . ._ . Lender's Address 444 S. FLOWER. LA 90071 P•C•Fee S �$ Pmmif Fee 685.50 �^^�`Ra�.N`"'`� � �� �'� � . � 1 •6 9 6,0 0 . p � Owbq(,OOU 1 cenify tho�1 have read Ihis opplication and state that the . . - G s-8 3 hsuaoce Fee 10.5� �DhV1 P/C K . obova informotio ' torrecL I ogree to comply with all Counfy in�eei�garon fee 0 a 2 G�8�] ordinonces an t e lows relating io building conslrutlion, To+al Fee 696.QD LDMA Pe m M•- and hareby u� �ize repreeentatives of this Coumy to emer � � j .,�_ upon the �roperry for inspection p rposes. � ' LDMA $75� $35 �,�.._ : F ,;.�t� �� ��/�/�p � � SEE REVERSE FOR EXPLANATORV LANGVAGE ' ' � � S�gnaNre o PPlicanr ar Agenl � pote -. . - . . . . . . . .. . . . � . � x � --""-•' , _ -- ° o T y . .� � ��- n '� v. .� f n N C�o �a o; c- t7 s �.n , '° � o � ,�, f0 c� � t°y o m 9' � r / Y O n �^ `F'' t0 G O .� ' Q / T N p ' � 7 p .�� Q O.. U �.� '� +� . . m '^ p � C� p , ! u7 > �j� O 7 . �, "' O <,' i � r � p � � Q_.. 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