HomeMy WebLinkAbout0804A WORKERS'COMPENSATION DECIARATION -� '.��� � �
I hereby a�;,m that I have a certificate of�o�,e�,�o self qpp�ICATION FOR BUILDING PERMIT
inture,or a cerfifimte of Workeri Compensofion Insurpnte,
� or a certified copy thereof(Sec.3800,�ab.c.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
7��C�05-279—O4ompony Nati onwi�,�,_, 2��
� Certified copy is hereby furnished. FOR APPLICANT TO F�LL IN BUILOING
ADDRESS
� Certified mpy is filed with iha coun�y buildin9�^sPe�- BUILDING 648 Armitos Place
fion dapartmeM. , A�DRE55
oar� 8/5/87 AppliwM THE ANDEN GROUP ciTrDiam d zia �ocnuTv Diamond Bai'
CERTIFICATE Of EXEMPTION FROM WORKERS' NO.OF BLDGS. NE4REST
COMPENSATION INSURANCE S�ZE OF tOT NOW ON lOi caoss sT.Diamond Bar BIVCI & Golden $ 1I1CJS
(This section nead not be completed if the parmit is for one ASSESSOR
hundred dollars($100)or less.) TRAa 4 2 5 8 0 BLOCK lOT NO. $ 1y�qp @pq( PAGE PARCEL
��� U ONE MAP
I certify thar�in the performance of the work for which this OWNER Np• — �� NO. � �3
permit is iu�ed,I shall not employ any person in any manner qpD�� P•�.B�){ 3 3 2 9 �� SPECIAL O
sa as to become eu6ject to the Workers'Componsation lawa. C� CONDITIqVS
CITY Covina ZIP 91722 V
'�ife Applicanl ARCHITEQO TEL. �
.�OTICE TO APPLICANT: If, afler making this Certiiicate af �ave Szan AIA No.445-4073 DISTRICi GROUP TYPE FIRE PROCESSEDBY p
ENGINEER
Exemption, you should become svbject to the Worken' � CONST. ZONE F...
Compensatio�provisions of ihe Labor Coda,you must forth- ADDRESS 31.4 N. First, Arcadia a l�l
with comply with such provisions or this permit shall be TEL. STATISiICAt CLASSIFICATION • APT. C NDO.
deemed revokad. CONTRACTOR O. Z
IICENSED CONTRACTORS DECLARATION ���. C1A55 NO.�OWEtt.UNi75
I here6y affirm thot I om licensed under provisions of Chapter 9 ADDRE55 AS above r,o.5105 6 0
(commencing with Section 7000)of Division 3 of the 8usiness ond ��� B SEWER MAG
Professions Code,and my licensa is in fuli force and affect. qTY C1A55 eK � VALIDATION
LicenseNumber 510560 �;�.C�a,s B sii'eFT1314 sToa�s 1 FaM�Es 1 oNEK
THE ANDEN GROf.� 8/5/8 7 N� r-, v�wanod
Gontrocfor �e DESCRIPTION OF WORK
ADD L� s6,820 , F�•p8Q4A
�I am exempr under Sat. 44E S�' A��R
B.SP.C.for�his roason SLAB ONLY REPAIR S �$o • • e ��
po�@; USE OF DEMOI ( ° •b B.O O
EXISTING BIDG.
Si nafure APPLICANT TEL. _
g PRINl fINAL � �/ . d o 6 f�U J�,
OWNER-BUILDER�ECLARATION DATE I �77
I bereby affirm that I am exempt from the Contrador's license P.S above d 8.1 7—8 7
�„J,pw fa�tha following reason(Section 7031.5, Busioess and ADDeE55 FINAL
ofeesions Code}: N 6y `C�:y't�t
� 6UILDING ',
1, as owner of fhe property, or my employees wilh ADDRESS �.F
wages as iheir sole compensation,will do the work and � ,„ •, �', � � . ,
fhe structure is not intended or offered for eale(Section ����T� ' � ' �
7044,B�siness and Professions Code). MOV�NG TEI.
� CONTRACTOR NO. � � ' ,
I,os owner o4 the property,am excivaively con�rocting �, y �+x�..
with licensed cammcrors to constroa the projeu(Ser AODRE55 �
tion 7044,Busineu and Professions Code). ' - �.
CONSTRUCTION LENDING AGENGY SEi BACK YARD Hwv TOTApROP pLINE WiOTH
I hereby affirm that there ia a consir�ction lending agency for FRONT
Ihe performance of the work for which thia permii is iesued p.L. .
(Sec.3097,Civ.C.). SIDE
v.i.
Lenderi Name ('i ti hank
5 7.5 0 WMA Ref.M
Lender'a Address 4 4 4 G. F 1 OW r, L.A. �0 71 P'C.Fee S Permi�Fse ,
� I certify that I have reod this applica�ion and state thar the Isauonca Fee 1 Q.5 0 L�MA p/C M
above inform ' n is wrrect.1 ograe to comply with all County Imes�igauon Fae�
'q ordinance nd Sta�e laws relating to buildfng conatruttion, io�ol Fee 6 8.� LDM0.Perm.M
and her y horize repreaentativea of this County�o enter
� up -y][y��n�tioned properry for inspeSfi�on purpoQses.
� �U(/J��,p V �� O� fEE REYERSE FOR EXPIANATORY LANGUACE
Signalura of Applicanr m Aqent poro .
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