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HomeMy WebLinkAbout1520A 1521A WORKERS'COMPENSATION DECL4RATION • �� 1 hareby affirm fhat I have a certHicote of[onsent b self �,� APPLICATlOiV FOR BUILDING PERMIT insure,or o tertificme of Worken'Compensation Inauronce, or a c f ie py r of 5 c a6.C� � � - �-� �- a4��1 COUNTY OF LOS ANGELES BUILDING AND SAFETY P�oNcyNo. Company AFTNA euaolNG � Certified copy it hereby furnished. FOR APPLICANT TO FILL IN ADDRES$ 24245 SEAGREEN D � Certifled eopy is filed with the county building inspec- BUIIDING tion departmant. A�or�ss 24 2 4 5 S EA E ���nY pare 1(23/84 ,�,Pi;w„�THE ANDEN GROUp an DIA OND B nv CEROSS57. CERTIF�fATE OF F�(EMPTION FROM WORKERS' ������ �� COMPENSATION INSURANCE SIZE OF L07 NOW ON LOT MAP BOpK GAGE PARCEL (This section need not be completad if fhe permi�is for one USE 20NE Maa /�j��� n��d�ad douo�s tt�oof«tesg.� TRAn 33 Q 2 0 e�ocK �OT NO. NO. � TEl$ SPECIAL } I cenify thot in the perforrtw�ce of tha work for which this OWNER NO _ CONDI710N5 � parmit is issued,1 sholl not employ any person in ony monner DISTRICT .GROtiD ttPE FIRE PROCfSSED BY Q so as to baccma subject to�he Wakera'CompensallOn LPws. ��R� � CONST. ZONE U Lt cm COUINA zir 91724 l� �`3 � O �Ufe ..AppIi[ant � � - . . . STATI5fICALClOS51FICATION APT. CONDO. !� �NOTICE TO APPUCANT: If, aher making this Cerlificafe�of '�CH��B��J' . $Z. NY.: � N� �uNp..�.O.. pyy�.�µTS`f� uVi xemptbn, �you should 6ecome :�bject�fo �he Wwkers'. ENGiNEER - a �- .;ompenaution prov�sions of the La6or Code;you must fort6- R��� -- $EwER nuP � � with comply with such provisians or this permit ahall be � � � � Z deemed revoked. - �pNrxaCiOR THE ND ��� . 0K. PG, VAl10ATIQN LICENSED CONTRACTORS DEClARA710N iK, ' I heraby affirm thot 1 am licensed under provizions of Clwp�er 9 ADDRESS 1��4 P A R KV I E W D R.No. 3 71 S 8 0 yI�WATION (commenting wifh Seclion 7000}of Division 3 of the B�siness o� LIC. Profassions Codn,and my license is in tulf forco and effec�. CiTv C OY I NA anss $ S 6 6,9 Q 0 � .. SQ.Ff NO.OF NO.OF � CHECK - Lkonfs Number Ty���4�_lie.GMae g s�ze 15 7� stoaies S FAMilIES oNe . DES�RIPTIONUXWORK NEW S ContracrorTHE ANDP.N �ROl7¢6� 1�23 Rd �� ❑1 am sxampt under Sea OF S ZN L A� � - - AL7ER � FINAI 1 B.SP.C.For ihls reafon REPAIR � DATE �II I f��' �� S 2.O A. . Date: X STNG BIDG. OFMOt ❑ gY AL I\ ..��"_ �{� � � �G� s�srwt��a "rP"a Ni` Na. 81 r •2 2 8.4 8 � OWNER-BUItDER DECLkBATION - '�, I here aff'wm�hat�om eeem from ihe Contrac�ors License ► x i �aw fof the following reawn f Sed'a��031.5,eua�nass a�d ADDRE55 10 74 P AR KV I.E W D R. C OV I N A C A ••c 2 8 4 8 0 Profeeslons Code): � ak �BUIIDING �2� 3��+4 [� � 1,as owner of rhe properfy, or my employaea with ADDRESS \ wages aa Iheir wle compensation,will do�he wwk and , i � the structure is nof intended or offered for sale(Section lOC�4utY . 7044,Busineu and Professions Code). MOVING TEL. � I,as owner of ihe proparty,am extlusively contracting NTRACfOR r,o. �1 5 21 A with licensed conlroctors to[ons�ruct tha project(Seo- ADDRE55 �� � • •�� tion 70M1,8�sineu and Vrofessions Code). REDUIRED TO7AL SE7BACK FROM EXIST. CONSTRUCTION LENDING AGENCY �gq�K VARD HWV pROP.tIN wiDiH � I •3 9 4,5 0 I hereby oifirm thal lhare is o conatrunlon lending agency for FRoriT the performance of the wwk for which ihis permit is iuued v.t. • .3 9 4 5 G� (Sec.3097,Civ.C.). SIDE � - `'` 0213-84 m lender's Nome 7� p�/n .� P.0 Fee S �f�•7d Permi�Fee .���� Lender's Addrea � 1 certi{y Ihot I have�end thia applicotion and slote that the luuance Fee �•..5� above informa�ion ia conect.I agree to comply with all County Inveviqarion Fee _/ ordinvncas and Stote la a relating to building conslruction, � To�al Fea -3 9�'•-+� G and h ra6y outhorize r esentaiives of this County to enter � up e above-menf oparty for Inspaction purposes. - �� � - � � �OJv �+15 SEF REVFASE FOR F%hIANATOMY IANGUAGE ' Sipna of Applimnt o. p r Date � .�i ,•� . y �1 ' _. ��� �. C.0 �" ' F . G y 3... u V'�.S2 r . ' .. ''u v � � �c .:�'X .,`=; Q N °. � � �' o , m T=� . t v X�`�,'.. r y�� . -G � a, y, . m s M.� � � � Kwaa13ooc� a � cie u ^ ou " �'M ' t) `n `' � m o'�'`y y '^ "p n y i` �a M S y'+ c i. . v e_� � i fl; � - p v �o.G n�N c�M c` ?3.�f i'�"�,., o ��.�: i e.� i i, ��.. °d � y - .. . , . � � F�,� .. ���� ��� y O c � d n�.K�- ,,, e �� :1� � �3 . . � OVT•l3,CMCp�R'..L` .CyO"± dt� ?' 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