HomeMy WebLinkAbout1526A 1527A (13) WORKER$'COMPENSATION DEGLARATION �
I hera6y affirm that 1 have a cenfficate ot consent to self Q APPLICATION FOR BUILDING PERiV11T
insure,or a ceNifimte of Workers'Compansa�ian Insuranee,
or a cartifi3d c��.tl�r�e�f(S���BO��p C.) lJ
PolicyNos Company AE�NA � COIJNTY OF lOS ANGELES BUILD{NG AND�SAFETY
� Certified copy is haraby furnished. fOR APPUCANT TQ FILL!N BUILDING
ADDRESS
� Cerfified copy is filed with the county building inspec- BUIl01NG
Tiondepartmenf. ADDRE55 24233 SEAGREEN DR, iocautvDIAMOND BAR
oate 1/23/84 ,qPP���a�� THE ANDEN GROUP cn, D NEAREST
ZIP CRO55 ST.
- CERTIFICATE OF EXEMPT�ON FROM WORKERS' NO.OF BLOGS.- 1 ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEI
(This section need not be completed if tha permit is for one T�R 33 0 2 Q B�OGc t0T NO. 9 u�z�E NwP f�3-
hundred dallars(310D)w less.)
OWNER THE ANDEN GROUP No818 967- 41 con�i�iiioNs T
1 tertify that in the performance of.the wwk fot whith this . ..d
permif is iuued,I sha�l not employ any perwn in any manner �ISTRICT GROUP ttvE fIRE PROCESSEp BY �
w us to becomesubjetl to fha Workars'Compensafion LOws. ADDRESS 10� AR D j CONS71' zOnle U
. GTY (,' ZIP 91�]z G �a �J � � �
Dale Applicant� .� . . .. . . � STAT�STKAL CIASSIFtCATION APt. CONpp. �
�• YOTI�E TO APPIICANT: If, after moking thfs Cepificate�af ARCHLTEQOR� � .7EL� ._,. V
� Er, �r,�ea BQVE`SZANY No. . 5-4-07.3 �,,,o; po t'I
aemption, you should become��subjeet--�o �he Workers' � . oweu..ururs_ u,
.:ompenwtion provisions af the La6or Coda,you must fonh- ,y�REu314 N. F I RST l�r/E. AR D IA C sEwee Mo,p �
with comply with wch provisioas or ihis permit aholl be , - � � - -. � � z
daemedrevoked. . CONiRACTORTH ANDEN GR UP T�`�.967-@641 � �� �, vAuoAnoN -
LICENSED CONTRACTORS DECLARATION
t1C.
I hereby affirm that I um licensed under provisions of Chapter 9 ADDRE55 S O�I 4 PA R K V I E W D R, r.,o.3 715 8 Q YALUATION
(commencing with Saction 7000)af Division 3 of the 6usiness and ���
Prolessiona Code,w�d my license is in f�ll force ond effect. CiTv C OV INA ��µ�,5 B f j � �
54.FT. NO.OF Np,pF CHECK
ucense t��mber 3 7158 Q ���C�� B s¢e 2 4 3 5 STORIES S FAMILIES 1 on�
ConnaciorTHE ANDGu r_Rnira�e_t i�/ua_ �ESC�RIP��IONOFOWORK CONSTRUCTION NEw � s
❑lomexemptunderSec. OF SINGLE FAMILY HOMES ADD � r.152.6A
B.&P.C.for this reawn RE ARR � ��` n ( ��� �� �� �2�
USE OF 3 2 5.,�,�
Date: EXISTING BIDG. DEMOL ❑ srµ ���� I •
SignoWro . . .. . . APPLICANT TEL
_ OWNER-BUIlOER�ECLARATION �a�r�r THE ANDEN GROUP No. -9541 .• •3 2 5,7 7�
�I here6y affirm thot 1 om exempr from fhe Connocror's Ucoma AD�kE55 10 7 4 PA R KV I E W DA. C OV I NA C �' G 2 1 3-8 4
Low fw the following reason(Section 7031.5,Businsu ond
Professionz Coda�: � � pp
� � 1, os owner of 1he o Y P � BUILUING
{x perfy, or m em lo es wifh ADDRE55
. woges as iheir aole tompentation,will do ihe work and
� the structure la not lntended or offered for sale(Section ��iR� . , �1 5 2 7 A
7044,8�sineu and Professions[ndeJ. hnovi� iE�.
� . I,as owner Of fhB prOpBfty,am exduaivaly toniratling C NTRAROR NO. �• • • • �� I
wirh licenmd contractors to conahoct the projea(Sec- Ap�E� i
tion 7044,Business and Rofessions Code). � •�j rj$,�p
� REQUIRED TOTAt SEfBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK Y�� H� pROP.LIN WIDTH - • �.�J��O O
I here6y affirm thpt tbe�e ia a construction lendin9 apency for . FRONT J, � `-'
the performance of ihe work for which fhia permit ia issued -v.L Y� � ��
0 ►se�.��.c,..c.>: P� s� /S 0 2 1 3-8 4
�
ta�ders nwm@ y
$ P.C.Fee S .7���/ Permif Fae ���SU -
Lander"c fWdress . ... _
,� I.certify ihot I hove raad this applicmion and amte that the � issuonce Fea O..�
:� above information is cwroct.I aprae io comply with ail Couny In�esripation Fse e
wdinancas and State la relating fo building construction, Toto1 Fea .J✓f`'y
�Y'i and h ra6y outhorize re� senlativas of fhis County lo eMer
��5 uqu a obove-mantb� loperfy fw inapection purposes. .. .
� 1 / !��d /
�/V � �!J fS�•�' � SEE qEVE0.SE FOR E%1uN�iQar�,�yq.W.r,.[
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