HomeMy WebLinkAbout0801A WORKERS'COMPENSATION DECLARATION - +� J'�
I hereby a4firm Ihot I hove a cerfificote of consenl to eelf APPLICATION FOR BUILDING PERMIT U
insure,or a cer�ificate of Woikers'Compensation Insuronce,
or a cerrrfied co thereof�Sec.3800,Lab.C.) COUNTY OF LGS ANGELES BUILDING AND SAFETY
7Pai�C�05—��19—Ogo��Y Nati onw�de Z�C
� Certified copy is hereby furnished. FOR APPIICANT TO FILI IN BUILOING
ADDRE55
� Certified topy is filed with the couMy building inspec- BUIIDING 664 Armitos Place
lion deparfinent. ADDRE55
Date 8/5/87 Applicant THE ANDEN GROUP arrDiamond Bar nr �ocnuTr Diamond B
CERTIFICAIE OF EXEMPTION FROM WORKERS' NO.OF 6�DG5. NEqRESi
COMPENSA710NINSURANCE SIZEOFlOT NOWONLOT CROSSST.D1dfi1011CI $$r $].VC7 & Golden S ings
(This section need nor 6e completed if the pe�mit is for one � r2nCT 425 B O BLOCK lOT NO. �ESSOR
hundred do�lars(5100)o�less.) �P�� PAGE PARCEL
TE�' USE ONE NaP
I certify that in ihe performance of the work for which this OWNER NO. — �i`� �,p, ( �-3
permit is issued,I shall not employ any person in nny monner qDORE55 P•�•B�X 3 3 2 9 �G" SPECIAL �
so as ta become subject to Ihe Workeri Compensa�ion Laws. O C/�(7 CONOITIONS
%"`�ae A lican� CiTv COVlrid Zip 91�22 V
ATICE TO APPIICANT:If after making�Ihis Cenifitate of ARCHI7ECi OAD TEI. DISTRICT GROUP iYPE FlRE PROCESSED BY p
ENGINEER ave Szan AIA No.445-4073
Ezemption, you should become sublact to the Workers' ONST. ZONE U
, Compensotion provisions of the Labor Code,you must forth- qDDRESS 314 N. First, Arcadia �� W
� with comply with such provisions or this permit shall 6e TE� 0.
deemed revoked. SiATISTICAI C1A551FICATION APT. ONDO. Z
CONTRACTOR O.
LICENSED CONTRACTORS DECLARATION �i�. QASS NO. � DWFLL.UNITS
I hereby offirm that I am licensed�nder provisions of Chap�er 9 ADOrtE55 AS above No.510 5 6 0
(commencing with Section 7000)04�ivision 3 of the Business and ��� SEWER MAP
Professions Code,ond my license is in full force and effect. � CITY QA55 B � � VALIDATION
510 5 6 0 B s¢e�314 sroa�s 1 c"n°nn°Es 1 CONfK
License Number Lic.Class
THE ANDEN GROt� 8/5/S 7 DESCRIPTION OF WORK ^ VALUATION
Eontroctor te NEW �
ADD u S 6,82D , :c080.1 A
�I am ezempt under Sec. Gd d
ALTER � #�� • • s'�
B.&P.C.for fhis reason SLAB ONLY REPAIR ❑ s
Dote: USE OF � • •6 a�Q
EXISTING 6LDG. DEMOL ❑
Signature , APP��G4NT h�' FINAI /// � � �b II'n��
OWNRR-BUILDER DECLARATION �RiN7 pA� t /5-/�
. I heraby affirm that I am e■empt from rhe Contractor'a License AS above � 0 8.1 7-8 7
�,aw for Ihe following reason(Section 7031.5, Businesa ond ADDRESS F�pp� ��
���vfeasions Codej: H � 6y �� ,
� I, os owner of the ro er y P y BUILOING -
p p ry, or m em lo ees wilh ADDRESS i�
wages as thair sole compensation,will da�he work and ����TV , � � -
the structure is not infended or offered for sele(Section - �
7D44,Business and Professions Code). MOVING TEI. -
� I,as owner of the property,am @xclusivaly connacting ONTRACTOR ND.
wiih licensed conlracfo�s to consiruct the project(Sec- qDDRF55 �
lion 7044,Business and Professions Code).
CONSTRUCTION 4ENDING AGENCY SE7 BACK �ARD HWV TOTAPROTP LINE WIDTH �
I hereby affirm that�here is a construction lending agency for FRONT
�he parformance of the work for which Ihis permit is issuad c.l. -
(Sec.3097,Civ.C.). SIDE
P.l.
lender's Nama C1t.lbdrik
5•�•5 0 LDMA Ref.k
` lender'sAddreu_444 S. Flower. Ir.p.. 9��71 P�C.Fme1 Fxmi�fes �
� I cerlify Ihet I have road this applicotion qnd state ihat the luuance Fas 1�.5 Q LDMA P/C N �
above infor tion is torrect.I agree to comply wi�h oll County Im�stipation Fee
$ ordinance a d S�a�e Icws relating lo buildinq conatruction, Toral Fee 6 8.�0 �ht4 Ve�m.k �
and her or'e represantatives of this County fo anter
^ u on ' ned property for inspaLsyo�purp�s^J �
Ol / S[E REVERSE FOR E%PIANATORY tANGUAGE
$ignmure ot Applicant w Agent pale
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