HomeMy WebLinkAbout0819A WORKERS'COMPENSATION DECLARATION �^ - f'�
I hereby offirm thot� ho�e a�a�,;t��a,a of consent to self qpp�ICATION F4R BUILDING P�ERMIT
insure,or a certificate of Workeri Compensation Insuronce, L�
or a cerrflad co thereof(Sec.3800,lab.C.) CQUNTY OF LOS ANGELES BUILDING AND SAFETY
73WC005-1��J9-0�16 3/A
PolicyNo. ompany Nationwide
� Cerrified capy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRE55
� Certified topy is filed wi�h the county building inspec- BUIIDING 652 Armitos Place
lion department. AODRESS
�o�e 8�5�$� Applicant THE ANDEN GROUP orv Diamond Bar ziv ioc,aurr
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATIONINSURANCE SIZEOfl07 NOWONLOT cRosssr.Diamond Bar BZVCl & Golden S rings
(Thia aection need not be completed if the permit ia for one 7RnCt 4 25 8 0 BLOCN LOT hi0. ASSESSOR
hundred dollars(5100)or leES.) �P��K PAGE PARCEL
TE�' USE ZONE MAF
I certify that in the performance of the work for which ihis OWNER n10. — _/ � r
permif is issued,I shall not employ any person in Cny monner P,Q.$Q}� 3 3 2 9 SPECIAI �
so as 10 became subje�t to the Workars'Compensotion Laws. ADDRE55 QQd CONDITIONS
O
ciTv Covina zia 91722 �?
���,te Applicant � �'
ARCHIlER OR TEL.
.OTICE TO APPLICANT: If, ofler mcking�lhis Cartifi[ate ot ENGINEER �ave Szan AIA No.445�-4073 DISTRICf GROUP NOP�T ZR�EJE VROCESSFDBY Q
Ezemption, you ahould become sub�act to the Workers'
Compenwtion provisions of Ihe Labor Code,you must fonh- qppRE� 314 N. First, Arcadia l J W
wNh comply with such provisions or lhis permit shall be ' p,
deemed re�oked. . TE�� STATISTICAL CLASSIFICATION APT. CONDO. Z
GONTRACTOR
IICENSED CONTRACTORS DECIARATION ���, 0.A55 N0.�DWELL.UNITS
I hereby affirm that I am licensed undar pro�isiona of Chopfer 9 A�DRESS �1S above �.510 5 6 0
(commencing with Section 7000)of Division 3 of ihe Business and ��� B SEWER MP.P
Profassions Code,and my license is in full force and effec�. U7v CLn55 BK � YALIDATION
510560 B s°e�Y409 TORI�ES �. F MI�S Z CDNEK
Licenx Numbar Lic.Class
YALUATION
THE ANDEN GROi� 8/5/8 7 �ESCRIPTION OF WORK NEw
com�acfo� r� noo s , :�0 B 1.9 A
I am azempt under Sec.
Gara e 6 �
AUER
B.6P.C.for this reason $LAB ONLY REPAIR ; �''• • • • �
oofa: use oF o�oi i • •7 4.2 5
exisrwc e�oc.
SignOture APPUCANT '��. FINAL r x
OWNER-BUILDER DECLARATION PRINT pATE �/ L' fj'-� • � �.7 C,:G J c;
I hereby affirm thot I am exempt from the Contractor'e Licenne p15 above /
�,nw for Ihe following reoson(Section 7031.5, Buaineaa and AooRe55 FfNAL � d�� %"8 7
ofesslona Code): . � By ����,s2� �
' � 6UILDING
I, as owner of The proper�y, or my employees wifh ADDRESS
wages as their sole compenaotion,will do the work and � '
the structure�s not intendad or offered for wle(Section ����T� � � �
7044,8usiness and Professions Codej. MOVING TEL. �
� I,aa owner of fhe property,am eaclusively controcfing CONTRACfOR NO. �� � .,
with licensed contractors to consiruct the projeU(Sec- qODRE55 �
tion 7044,Busines3 and Professiqns Code). �,
CONSTRUCTION LENOING AGENCY REQUIRED YARD HWY OTAL ETBA K
SET BACK PROP.LINE WIOTH
I hereby affirm that thera is a construttion lending agency for FRONT
ihe performance of the work for which ihis permit is issued P.�.
(Sec.3097,Civ.C.). SIDE
v.�.
Lender's Name Citibank
P.C.Feet � PermNfee 63.75 ��a'f.�
m lendeisAddress 444 S. F10wEx'� L.A. 90071 ,
� 1 cerr�fy rhor I hove reod this application and slate thot the Issuan<e Fea 1 O•5� �onv aic M
_ above infor tion is correct.I agree to comply with oll County In�esilgo�ion Fee
ordinanc d State laws relating to 6uilding conslruclion, Totol Fee LOMA 7erm.k
and her a th rize�epresantafives of ihis County fo eMer
M1 up n v ' ad property for inspect�n�
(Y7 SEE REVERSE FOR ExPIANAiONY LANGUAGE
Signature of Appliconf or Ayenf Do e �
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