HomeMy WebLinkAbout1520A 1521A (15) 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
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