HomeMy WebLinkAbout0832A WORKERS'COMPENSATION DECLARATION � �""'* f� '
I hereby affirm that I have a�e�,;f;�a,P af consent to self APPLICATION FOR BUILDING PERMIT ��;
insure,or o certificote of Workers'Com ensation Ins�ronce,
or a certified copy thereof(Set.3800,Lab.C.) 1/A COUNTY�F LOS AN6ELE$ BUILDING AND SAFETY
7��7C�05-279-0�16
o icy o. ompany Nati nnwi de
� Cenified copy ia hereby forn�shad. FOR APPLICANT TO FILL IN BUILDtNG
ADDRESS
� Certified copy is filed with the tounty buildfng inspeo- BUILDING 662 Armitos Place
fion deparimeM. ADDRE55
oarB 8/5/87 Applitant THE ANDEN GROUP c�rrDiamond Bar z�v9 76 iocn�iTrDiamond Bar
CERTIFIG4TE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATIONINSURANCE SIZEOFLOT NOWONLOT CROSSST.D1dTIlOI1Cl Bar BZVC; & Golden S ings
(This section need not be completad if the permit is for one TR,,cr 4 2 5 8 0 B�Wc �Oi NO. 2 3 ASSESSOR
h�ndred dollars(5100)or less.J N✓+P BOOK PAGE PARCEL
TEL. USE NE � '� ��
I cenify tho�in the performance of the work for which this OwnteR NO. — )/ p�p
permit is issued,I shall nol employ any penon in any manner P,Q.$Q}� 3 32 9 " SPECIAL
so as to become sub�eci to ihe Workers'Cortrpensofion Laws. � ADDRE55 �DO� CONDITIONS O
CITY Covina 21p 9�.722 V
^��Oe Applitont ARCHITECTQ TEt. �
.JTICE TO APPtICANT: If, after making�this CeAifitate of ENGINEER 'Dave Szan AIA r,o.445-4073 DISTRICT GROUF TYPE FIRE PROCESSEDBY
Exemption, you should 6ecome s�6ject to the Workers' CONST. ZONE
_. Compensarfon provisions of the Labor Code,you must forth• qDORESS 314 N. First, Arcadia �A W
with compiy with auch provisiana o� Ihis permit shall 6e TEI. 57ATISTICAL CLAS TION APT. NDO. n'
deamed revoked. � Z
CONTRAROR
I�CENSED CONTRAGTORS DECLARATION ���, C1A55 NO. DWEIL.UNITS .
I here6y affirm thot I am licensed under provisions of Chapter 9 aDDRESS AS above ,.�.510 5 6 0
(mmmencing with Section 7000)of Division 3 of 1he 8usiness aed ��� �'n'ER M�`P
Professions Code,ond my license is in full force and effect. Ciiv CLA55 B � � VALIDATION
510 5 6 0 B s¢eFi'15 3 5 s"roa�s 2 �i°Es 1 oN� M��i����
license Number Lic.Closs
VAtUATION
TAE ANDEN GROII� 8/5/87 OESCRIPTtON OF WORK NEw
� Conlroctor fe ;
41 H S F ADD
�I am exempt undar Sea GdTa e � �0 8 3�2 A
ALTER
B,&P.C.for this reason SLAB ONLY REvnIR = �° • • • ' r
pqfe: USE OF
EXISTING BIOG. D�L � e •�](�,2 5
$ignafure APGLICANT ie�. FINAL
'OWNER-BUILDER DECLARATION VRIN7 � DA�E /�✓ � e a o']/y,��j�
1 hereby affirm that I am ezempt from the Contractoi a License AS above
�,l.aw for Ihe following reason(Section 7031.5,8usiness and ADDRESS FINAL �/� �g,T 7�'��]
�fessio�a Code): By �ZY���'""�
JI, as owner of the properfy, or my employees wifh ADD E55 ' , , ..
woges as rheir aola compensation,wiil do the work ond ��A�itv , '
the atrucrore is not intended or offerad for sale{Section � -
7044,Bosiness and Professions Code). � MOVING TEL.
� I,as owner of 1he properly,om ezcl�sively tontracting C NTRaCTOR NO.
wifh licensed coMroctors to construct the projetl(Sac- ADDRE55
tion 70A4,Business and Professians Code).
CONSTRUCTION LENDING AGENCY SE7�gq� VnRD HWY T�TApROP IINE WiDTH
I hareby offirm that Ihere is o cons�ruction lending ogency for fROt�T
the perfo.mance of the work 4or which this permit is iasued p.L.
� (Sec 3097,Civ.C.J. SioE �
v.t.
Lender's Name.C1t1b3ri�C
6 3.7 C, IDMA Ref.M
m Lender'sAddress 444 S. Flower. L.A. 9�0']1 P'C.FceS vermnfee �
� 1 cer�ify that I hove read this applicafion and alate ihot the �asuonca Fee 10•5� IDMA P/C N
� above inform lon Is correc�.I agree 10 comply wilh oll Counry in�esuga��on Fee
q ordinonces State laws relaiing�o building consfruct�on, Tobl Fee LOrnA vs�m.N
and her y �thorize representativea of this County to en�er
� upo�t v iioned properiy for insp�e�('o purposes.
F (/ !V �7 fEE REVERSE FOR EXPLANATORY LAN4UAGE
Signoturo of Appl�cc��w Aqenr e
FLSehS TC3 hPRl1CANF �I�5PECT0�'S NOTEB U6LT6�R-131�11.Uf•.R 1)1`.C(.AH.41'.LON . .
. . . .by aE`, I- .nFv t�� _, . .. _ .
i a� „
To: ' YFaWrned' _ � '.i<�.._ Lav� ic �cll :1 r a ,;at.� :,4I 5;
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