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1066A 1067A (5)
, . „ �• WORKERS'COMPENSATtON DECLARATION � � � � � � � � I hereby offirm iho�I have a tenificaie of�a�=e�„o=e�f ��APPL�ICATION��FOR BUILDI�Nt� PERMIT� � insure,or o certificote of Workers'Compensa�ion Insurance, , or a certified copy thereaf(Sec:3800,teb.C.) UNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo.�73WCOOS—���P�16 NATIONWIDE ._ (MODEL) Plan 36�� � � - Cerrlfied co is hereb furnished. - ADDRE55 609 S. Junewood Place ❑ PY Y " FOR APPLICANT TO FILL IN � Cerrifled copy�s filed with�he covnty boild�ng inspec- " gUi�DwG - tion depariment. - � ADDRESS 609 S. Junewood Place oore 6-30-87 Applicont THE ANDEN GROUP an DIAMOND BAR zir 91765 iov.uTv DIAMOND BAR CERTIFICATE OF EKEMPTION FROM WORKERS' � �� � � NO.OF BIWS. - . rrEAREST - COMPENSATION INSURANCE� . SRE OF tOT NOW ON tOT ceoss sr.DIAMOND BAR�BLVD. +�GOLDEN SPRING Qhis settion nead not be comple�ed if the parmi�is for one - _ .. a5SES50R - . hundred dollors(SI00)or less.) rRncr-43435 - - e�ocK LOT NO. 5Z MAP BOdC� � PAGE PARCEL TEL. U ONE �P owNce THE ANDEN GROUP No. 967-9541 I cerfify that in the periormanca of Ihe work for which ihis � NO. /� '� permit is iesued,I shall nol emplay any person in ony�monner SGECiAt . _ so as to becoma s�bjett fo the Workers'Compensotion lows. �� ADDRESS P.�. BOX.3329 ��C�(� CpNpITIONS 0 CITY COVINA ZIP 9],]'22 V Dote Applicon� ARCNiTEQOR TEL. � NOTICE TD APPLICANT: If, af�er making�this'Certificole of ENGiNEER DAVE SZANY AIA r,o. 445-4073 DiSTRiCT GROua ivPE FIRE v�tOCE55ED BY O Ezemp�ion, you should become sub�ecl to the Workers' - j� COI�$I, �{I 2 U �mpensotion provieions of the labor Cada,yau must forth- ADDtiE55 1� /(•3 I V W {nc �omply with such provislons or this permit shall be , TE� p; deemed revoked. , STATISTICAI ClAS51FICATION A7T, CONpp. � mNTancroe THE ANDEN GROUP No. � UCENSED CONTRACTORS DECLARATION MSS NO. ��� � DwEtL UnliiS + . Z uc. I hereby affirm ihat I am licensed�nder p�ovisions of Chapter9 ADDRE55 AS ABOVE n,o. 510560 (commenting with Section 7000)of Division 3 of Ihe 8usiness and ��� SEWER mnP Professions Code,ond my license is in full lorce and eNe�t. CITY - - � M55 ��� � eK � VAtIDATION 510560 B SI�ZEFT LGSH STORI�ES 2. �ILOIES 1 ONEK' Litensa Number �Lia Class � � - � VALUATION � Contractar THE ANDEN GROUP Dole 6-3O—H7 ��RIPTION OF WORK - N� ADD � S 100,000 �lada . ❑I am eaemp�under Sec. GARAGE 456 SF 6.8P.C.for thfs reason AITER � s �-/ �J'�-,` � �1 0 b 6 A � USE OF REPAIR ❑ /I� / V u .. �• • • • •'� . � - Datr.� E%ISTING BIDG. DEMpL ❑ _ � •{�2 2.�3 ' S19naturC � . .. . ..... '' APPIICANT .. . .-TEI. FINAL OWNER-BUILDER OECLARATION � PRiNi THE ANDE N�� DATE �� � • •C�2 O'J i� I hereby afiirm thaf I am exempl from Iha ConlradorS License � qDDRE55 AS L�B�VE tow for the following reoson(Secrion 7031.5,Business ond FINAL �/� � ��L 6�8'] Professions Code): � � �-� pReseNr 8Y 1R. ❑ BUitDitaG 1, os owner of tha property, or my employees wilh ADDRE55 wages as their sole compensation,will do the work and , �he structura is not fntended or of(ered for sale(Section ����TM �� 70d4,Business and Professions Code). � � � MOVING - � � � TEL � . � I,az owner of the properly,om e.clusively contracring CONTRACTOR NO. '.'_"�� O�7 A �wi�h lirensed contractors fo construct�he projeU(Sec- �- - �� ��� �-�� tion 7044,8usiness and Professions Code). ADDRE55 - �� • �� � ' r� � ! �� � � � .� REQUIRED TOiAt SETBACK FR M I •- � f ���I�i� � t CONSTRUCTION IENDING AGENCY - - �i gq�K YARD HWY pROP.LINE WIDTH �� � -`.�- � � I J O 7�O O 1 hereby oifirm�ha�thera is a construUion lending agency for fRON� �' ' �,� }� �.,- ' '••�� ° •5 n 7��� tha performante of the work for which this permi�is issued P.t. . . � . � (Sec.3097,Civ.C.). sioE • • CITIBANK P.�. _ _;_ . '� 0 8 2 6-8 7 Lender's Nama f � �}�'.i���,� � P.C.Fae�:� Ve.mu Pee . 496.50 �DMA Ref.N ���•J � ' � lendeisAddress-.444 S. FLOWER. LA 90071 10.50 , I cerfify ihaf I have reod ihis applicalion ond sfafe�hat the . � is�ua�ce Fse iDMA P/C M above iniormolion corrocl.I ogree to comply with all Couny invev�garon Fee � ordinancee ond a laws reloting to building comtructian, Totol Fae 507.00 lpMq P�rm.M. ond hereby repreeentalivea of thls County 10 enter "" � _ ' ' ; vpon t - en wped�for Inspecflon purposes. ' - (� LDh1A $75 $35 ,� .!�' '' , ,�_,./,}...` , . 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