HomeMy WebLinkAbout0833A WORKERS'COMVENSATION DECIARATION �
insureborafcertifcateofWorkenr'Compensatonensurane" AP��ICATION FOR BUILDING PERMIT �
or o cer+ified copy thereof�Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
7�4iICQ05-279-00�16 1/A
o�ty o. ompanyNatinnwidt�
� Certified copy i�hereby furnished. FOR APPLICANT T�FILL IN qppDl5,5
� Certified topy is filed with ihe coun�y 6uilding inspat• BURDING 658 Armitos P 1 ace
tlo�depariment. A�ORE55
oe,B 8/5/87 Applicon� THE ANDEN GROUP c�r�iamond Bar z�r91765 �ocnuTvDiamond Bar
CERTIFICATE OF EXEM7TION FROM WORKERS' NO.OF BtDGS. t�E.4RE5T
COMPENSAiIONINSURANCE SiZEOCL07 NOwOt�lOi ceosssrAiamond Bar BZVC� & Golden Sp ings
(This seciion need�ot be completed if the permit is for one rRncr42580 BLOGK lOT NO. 21 AUES50R
hundred dollors(5100)or less.) NJ+F BOOK PAGE PAR�L
TEL. U ONE NOP �I
I certify thm�in the performance of the work for which this OWNER N — / r.3
permit is issued,I sholl no�employ any person in any manner P,Q.$Q}i' 3 3 2 9 � ���A� �
so os to become aubjact to the Workers'Compensation Lows. A��SS GU CON�IilONS U
�cre Applicanf arr Coviria ziv 91722
.OTICE TO APPUCANT: If, ufter moking�this Certificote of ARCHITECT O TE�� DISTRIQ GROUP TYPE FIRE PROCESSED BY �
eruGiNeeR �7ave Szan AIA No445-4073 NST. ZONE t—
Exemption, you should become su6ject to the Workers' ��
Compenwtion provisions of the La6or Code,you muat forth- pDDRE55 314 N. N'lY'S't� Arcadia la W
with [omply with such provisions or this permit �hall ba TEL. STAi15TICAl CLASSiFICATION APT. NDO. y
deemed revoked. CONTRACTOR O.
IICENSED CONTRACTORS DECIARATION CLASS NO.��WELL.UNITS z�
LIC
I hereby affirm�ha�I am licensed under provialons of Chapter 9 ADDRE55 AS above No510 5 6 0
(commencing with Section 7000)of Diviaion 3 of the Busineu and IIC. ��R�'P
Profassions Code,and my license is in full force and effecl. CiTY CLA55 B BK � VALIDATION
510560 B sieFT1535 SOR� 2 F MIOLIES 1 CONEK
License Number Lia Clau �
VALUATION �
�HE ANDEN GROUg S�S�H 7 DESCRIPTION OF WORK NEW �J ��g p g
Comrocto ale ADD f
�I om exempt under Sea a e �y��R � � �:Q$j,��Q
B.6P.C.for thls reason SLAB ONLY REPAIR ❑ : �. � . . � �
Ddte: USE OF DfMOI ❑
E%ISTING BLDG. � � �7�I,2 5
Signature APPLICAN7 TEI. FINAI !�/
OWNER•BUIL�ER DECLARATION PRinIT .. ppTE `� �F�y •s a%1[:2$�
I hereby affirm Ihat I am e.empt from the Contractar's License qpDRESS AS above FlNAL
�law for the following reason(Section 7031.5, Business and ye//��y �Q� 7�8'�
. ofessions Code): sN 0�� _
� I, as owner of tha properry, o� my employees with A�pORE85 ��. �
wagas as their sole compensatian,will da the work and ' . � -
�he siructure is nm intended or affered for sale(Section ��'��TM
7044,B�sinass and Profas:ions Coda). MOviNG T��� � `
� I,as owner of the property,nm exclusively connacting CONtRACiOR NO. , - t:
with licensed controcfors to construcllhe prolect(Sec- qDDRESS '
�ion 7044,Business and Profeuions Code).
CONSTRUCTION LENDING AGENCY SET�BACK YARD HWv T�T'�'p OT0.lME WIDTH
I bereby affirm that thera is a construction lending agency for FRONT
the performance of tha work{or which thia permil is iasued P.l.
(Sec.3097,Civ.C�. SIDE
P.l.
lender's Name Ci ti.hank
LDMA Ref.M
m �endeis<+dd.ess444 S. Flower� L.A. 90071 PC.FeeS �.m�tFsa '
� I certify that I have read ihis application and stale that the iuuance Fee IDMA P/C N
above informotion is correct I agree�o comply with oll Caunty Investiqation Pae
'q ordinances a ate laws relating to building construction, imal cea I�MA Pe.m.M
R and hereb ut rize representatives of this Counly to enter
$ upan the - ioned property for inspecfian purposes.
' � SEEREVERSEfOREXPIANATORYLANGUA6E
� Signot�re o Applicant rn Agenl fe
' PI�NS TO aPFt4�L,4Fdx aNgFEC�'•F�'S N'JTES U41'NtiN�B['ILUJ�:H Ut�:CI.Af{,0.�t70i�
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