HomeMy WebLinkAbout0802A WORKERS'COMPENSATION DECIARATION � +_ � �7
I hereby affirm that 1 ha�e a certifica�e ot consem lo self APPLICATION �4R BUILDING PERMIT �
insure,or a carfificate oF Workers'Compensation Insurance,
� or a certified copy thereof(Sec.3H00,lab.C.) � �
COUNTY OF LOS ANGELES BUILDING AND SAPETY
7���Cq��5-2'1J—O�y.�pany Nati[]nu.riAp BUIIDING
� Cerufied copy is hereby turnished. FOR APPLICANT TO FILL IN ADDRESS
� Certified copy is filed wi�h tha counly building inspec- BUiIDING
1io�depar�menl. P.DDRESS 660 Armitos Place
ome 8/5/87 Applitan� muR ANDEN C.RoUP CITY � ZIP �oa,uTvDiamond Bar
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF Bt�GS. NEAREST
COMPENSATIONINSURANCE SiZEDF�Ot NOwONtDi ceosssT.Diamond $dr BZVC� & Golden $ 1riCJS
(This setlian need not be completed if the permif is for one ,R,,c,42580 bLaCK LOT NO. MA7 OOK PAGE VARCEI
hundred dallan(8100)ar less.) ,
TE�' U ZONE NJ1P �
I terfify iha�in Ihe performance of 7he work for which this OWNER NO. — / �yp �7'�
permit is issued,I shall nof employ any person in ony manner qDDRE55 P•�.B�X 3 3 2 9 �` ���A� ��
so as la become subject to the Workers'Compensplion Laws. aC9 0 CONOITIONS �
arr Covina z�a 41722 �
�afe Applicant Lr
ARCNITECT O TEL DISiRICT GROUP TYPE FIRE PROCESSED BV
aOTICE TO APPLICANT: If, after making�ihis Certifica�e of ENGiNEER �dVE. Szan AIA No.445-4073 �
�Exemption, you should become subjett fo ihe Workers' / CONST. ZONE U
Compensa�ion provisions of�he Lobor Code,you must forth- qDozE55 314 N. First, Arcadia Gb W
wilh comply with such p�ovisions o� fhis permil shCll be TEL. STATISTIGL C1A551FICATION APT. N00. y
deemed revoked. CONTRACTOR O.
LICENSED CONTRACTORS DECIARA710N CLn55 NO.�DWEu.UNiTS Z
uc.
I hereby affirm ihot i am licensed under provisions of Chopier 9 ADDRE55 .�5 above No.510 5 6 0
(commen[ing with Secfion 7000)of Divisio0 3 of the 8usiness and ��� `"��R�P
Professions Code,and my license is in full force and effea. CITV CLA55 8 BK � VALIDATION
' SQ.FT. NO.OF NO.OF CHEIX
Li[enseNumbBr 510560 Lic.Class B SIZE STORIES FAMItIES ,1 ONE
VALUATION
Co�rroctorTHE ANDEN GROU��e H/5/H I DESCRIPiION OF WORK NEw
A� s 6,820
❑�am exempt under Sec. 4 4 8 SF AITER [] , `�8 Q 2 A
B.BP.C.for}his reason SLAB ONLY REPAIR � S �• • • • � �
Date: EXIST�ING BIDG. DEMOL I •+b H.D O
APPIICANT TEI.
Signaturo GRINT F�NA� ��� . • .b B.0 0�
OWNER-BUIL�ER DECIARATION DATE
1 here6y affirm�hat I am exempt from the Coniractor's License pooRe55 AS above fINAL
aw for the followiag reason(Saction 7031.5,Businass and A � n 8.� 7�a 7
`�•ofessions Cade): � N BY �y��z`1'�
� � 6UIL�ING
I, as owner of ihe proparty, or my employees wlih AooRESS
wages as their sole compensotion,will do the work ond � , � �� ;
ihe s�rutture is no�in�ended or offered for sole(Section ���ITY
7044,Business ond Profeuions Code). MOVING TEL.
� I,os ownar of�he property,am ezclusively Conhpcting CON7RAG70R NO.
with licensed contraciors to consfru[t Ihe prajoct(Sec- qppRE55 �
tion 7044,Business and Professions Code).
CONSTRUCTION IENDING AGENCY SET BACK YARD HWY TOTApROP.�LINE WIDTH
I here6y affirm thot there is a constr�ction lending ogency for FRON7
the parformance of the work for which this parmi�is issued P.L �
(Sec.3097,Civ.C.�. SIDE
P.L.
Lander'a Name �''i t i F�a nk
5 7.5� 4DNv1 Ref.N
P.C.Fee S Oerml�Fee ,
Lender'a Addross d 4 d R_ F 1 ow .r� T..A-. 9 O 0 71
I certi4y�hat 1 have read�his epplication and atate that rhe iswanc.ise 1�.5 0 WAnA PiC N
obove inform 'on Is correcf.I pgree to comply with all Counly inv�stipatfon Fee
ordinance n Stafe laws relating to bullding construction, To�al Fw ($.�Q LDM4 Pe.m.N
ond her y thorize represeniati�ea of thia Counly�o enter
upon t v ianed proparty foi i�apestio purpozea.
O SEE REVERf@ FOR EXPUNATORY LANGVAGE
Sigmrure.of Applicont or Agenl Dote
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