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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,.[ �^ Sigrwtur of Applimnt a A Dote� . . . . . . . . ...�y k _ �, . N G S ' ..Y� S v� /�` � � G p m C � y .M� . p ' ,. . � .��Y� �� y , . . 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