HomeMy WebLinkAbout0834A WORKERS'COMPENSATION DECLARATION G �
I hereby affirm that I have o�e,,;F��e,P of�o�ge��,o self APPLICATION FOR BUILDING PERMIT . u
inwre,or o<e���fimfe of Warken'Com ensotion Insurance,
or o cernfied cop thereof(Sec.3600,Lob.C.) 1�B COUNTY OF LOS ANGELES 6UILpING ANU SAF6TY
7a�C�05-2�19—Ogompa�Y Nationwide
Certified copy�s hereby t�rn�shed. FOR APPLICANT TO fllL IN qp�p��
QCertified copy�s filed with the co�niy build�ng inspec- BUILDING 646 Armitos Place
tion deparimenf. ADDRESS
oo,a 8/5/87 aPPr�o�f THE ANDEN GROUP c�nDiamond Bar z�P 7 �ocn��rv Diamond Bar
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.Oc Bl�GS. NEAREST
COMPENSATIONINSURANCE SiZEOFtOT NOWONIOT caosssT.Diamond Bar BZVCZ & Golden S ings
�This section need not be completed It the parmit Ia for one � n55ES50R
hundred dollors($100)or less.� TRAR+�2 S B O etOCK LOT NO. Mqp BOOK PAGE PARCEI
tEl. �cc�n� Op '2
I cenify that�in ihe performonce of fhe work for which ihis OWNER NO. � i)_N `�
permi�is Iasuad,1 sholl not employ any person in any manner pDORE55 P+�•B�X 3 3 2 9 SPECIAL �
so as lo bemme subjecf b the Workers'Compenaotion laws. � (7 CON�ITIONS �
OTY Covina ZIP 9�72z V
�.GTICE TO APPIICANT:If,�l after�making��his Cartificafe of ANGINEER � iE�'. DISTRICT GHOUP �NST. ZONE ��ESSED BY p
E:empfion, you ahoufd become au6jecl to �he Workers' RDave Szan ASF1 No.445-4073 �
Campenwtion provisions of the Labor Code,you must forth� pDDRE55 314 N. F1YSt� Arcadia d W
wNh comply with a�ch provisiqns or Ihis permit shall 6e TEI, STAiISTICAI CLASSIFICATION APT. NDO. y
deemed revoked. �ONTRACfDR O.
LICENSED CONTRACTORS DECtnRAT10N C�o.55 No. �� owelt.uNiiS___._ z
uc.
I here6y affirm that I am licansed under provisiona of Chapter 9 AODRE55 A S db0 V2 No.510 5 6 0
(mmmencing wi�h Section 7000)of Division 3 of the Buniness and ��� ��R��
Profassions Code,ond my license is in full fwce and effect. CRV C1A55 B BK � YAIIDATION
510560 B 5°E°T1535 iSOR°5 +�, NO.OF CHECK
liconse N�mber Lic,Closs FAMILIES 1 ONE
VALUA170N
Controctar THE ANDEN GROLb81e 8/5/8 7 �ESGRIMION OF WORK A� ;7,8 0 9
❑I am exempt undsr Sec. G3Yd 2 �'
AL7ER
B.&P.C.for fhis reason SLAB ONLY REPAIR s �0 8 3 4 A
USE Oi
Date: E%ISTING BtDG. �E��
Sipmture APPIiCANi iEl. FINAL �/ � y� �• • • • ��
OWNER-BUILDER DECLARATION PRINT DAT@ 7 �/
I heroby affirm thm I am exemp�from fhe Connactor'�Ucense }�5 above �I • •7 4,2 5
�1vw for the following roaaon(Secflon 7031.5,6usiness pnd ADDRE55 FINAI}��f -
� �feasione Cade): � �� � al' /��!7P , • ° 10��'�J�
� BUIIDING .
I, as owner of fha property, or my employsss wilh ADDRE55 ��,� 7�8 7
wages as their sole compansation,will da�he work ond ��q�i7Y , � � � �
tha structure is no�Intended or affarad for wle(Section �
7W4,Busineas and Professions Code). MOViNG TEI. � .
� I,os owner of the properry,am exclusively contractinq NiaACiOR NO. .
with licansed confracto�s to construce the projec�(Sea q00RE5S � ��
tion 7p44,Business and Professions Coda}.
CONSTRUCTION LENDING AGENCY �7 gq�X YARD MWV T�TApROV.LWE WIDTH
I fiereby affirm that therv is o consiruc�ion lending agency for - FROnIi
rhe performonce of�he work for which this permir is issued v.�.
{Set.3097,Civ.C.). SIOE
P,L.
Lander's Name Citibank
P.0 Fea S Permi�fee 63.75 �DMA Ref.M
m Lender'sAddress 444 S. Flower. L.A. 9D071 ,
� I certify Ihot ave reod�his applicatlon and siote fhat the issuonce Fee 1�.5� IDNV.P/C M
� above Infor ot on is correct.1 agree to comply wifh all Counry ImesYgor�on Fee 7 4.z 5
q ordinanc a Stote laws relating to 6uilding constr�ction, io�a�Fee tDhv1 perm.M
and her y fhoriza representatives af this Co�n1y to enter
u n a 'oned property for inspaciion purposes.
_����,���Q� SEE REVERSE iOR EICPLANATONY LAN6VA6E
Signaturo of ApPlieane or Agant ]«_��_.r
7�a
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