HomeMy WebLinkAbout1516A 1517A (13)WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have o certificate of consent to self
insure, or o certificate of Workers' Compensation Insurance,
or o certified copy thereof (Sec. 3800, lob. C.)
Policy No83-CK-95Eo—CPA to t,,WNn
n Certified copy is hereby furnished.
0 Certified copy is filed with the county building inspec-
tion deportment.
Date 1/23/84 Applicant THE ANDEN GROUP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so os to become subject to the Workeri Compensation Laws.
Date I plioc;
NOTICE TO APPLICANT: If, after making this Certificole'of
cemption, you should become subject do the Workers'
.bmpensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit sholl be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 371550 Lic. Closs B
Contractor pe
❑ I am exempt under Sec.
B.BP.C. for this
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
( 1, as owner of the property, or my employees with
t wages as their sole compensation, will do the work and
` the structure is not intended or offered for =is (Section
70", Business and Professions Code).
❑ 1, as owner of the property, am exclusively controcting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is o construction lending agency for
the performance of the work for which this permit is issued
ZSec. 3097, Clv. C.). -
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and Itaby authorize representatives of this County to enter
uP9,9a above -mention �fi&roperty for inspection purposes.
Signatu7j6 of Applicant ornt Dote
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
UE REVEM FOR EXPLANATORY LANGUAGE
1.32577
••325,776
0213-84
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FOR APPLICANT TO FILL IN
BUILDI
ADDRESS
BUILDING
ADDRESS
LOCALITY
DIAMOND
_RAR
NEAREST
CITY74ATZ
ZIP 91756
CROSS ST.
NO. OF BLDG$.
ASSESSOR
SIZE OF LOT
NOW ON LOT
MAP BOOK RAGE
PARCEL
USE ZONE
MAP
TRACT
BLOCK LOT NO.
NO. 1.2—� 9
TEL
SPECIAL
OWNE
NO.
—
CONDITIONS
DISTRICT .GROUP TYPE FIRE
PROCESSED BY
ADDRE
CONS 11E,
le ei ,r
I
CITY rQVTWA
ZIP
ARCHITECT OR
.'., TEL
STATISTICAL CLASSIFICATION
&?0.
APF. CONDO.
ENGINEER.
NOM-4071CLASS
NO. DWELL. kiNITS/
ADDRESS
SEWER MAP
CONTRACTOR
TEL.
BK -PG,
VALIDATION
UC.
ADDRESS
NO.
VALUATION
LIC.
Cm
CLASS T1
104,775
SO. FT.
NO. OF NO. OF
CHECK
SIZE
STORIES FAMILIES
ONE
0
pI
$
DE$Ci ION
—CONSTRUCTION
NEW ISI
ADD ❑
OF SINGLE
FAMILY HOMES
REPAIR ❑
DA E E
_2 1 5 1. 6 A
USE OF
�`r'OL [1v
F
9 .... 21
EXISTING BLDG.
RINAL
i\ r r
UE REVEM FOR EXPLANATORY LANGUAGE
1.32577
••325,776
0213-84
�151,7A
1.55a00
••55800.'
0213-84
Os