HomeMy WebLinkAbout0835A ^-WORI�4R5'COMPENSATION DECLARATION J�
1 hereby affirm �hoi I hove o Cer�ifitote of consent ro self APPLICATION FOR BUILDING PERMIT
insura,or o certifica�e of Workers'Compensation Insurance, ��
�or o cerlified copy thereof(Sec.3800,lob.C.} j/p, COUNTY OF LOS ANGELES BUILDING AND SAFETY
�v3o�c�'y�05-279-0(����y NatinnwiAa
� Cer;iNed copy is hereby furnished. FOR APPLICANT TO Flll IN BWIDING
nooaess
� Cerfified topy is filed wilh the couMy building inspec- BUItDING 66 5 Armitos P laee
fion depariment. AODRESS .
Date 8/5/87 Applicant TAE ANDEN GROUP c�rrDiamond Bar z�r9 765 �ocnurvDiamond Bar
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT N W ON LOTS CROSSSST.D1dRlOI1C� $dY' BZVC� & Golden S lri 5
COMPENSATION INSURANCE P g
(This section need not be completed if the permit is for one ASSESSOR
hundred do�lars($100)or IB55.) TRACf 4 Z S H O BLOCK LOT NO. 15 MqP BOOK PqGE PARCEL
TE�' U ZONE � I/ _�r�
I certify fhat in tha performance of the work for which this OWNER NO. — / �,p � ,�,
permit is iss�ed,I shall not employ any person in ony monner qDDRE55 P•�•B�X 3 3 2 9 " p SPECIAL �
ao os to become aubiect to the Workers'Compenaation Laws. GON�IT�ONS 0
cirv Covina z�a 91722 v
/�"ti)e Applimnt ARCHITECT O TEL. �
JTICE TO APPUCANT: If, aher making�lhis Certificote of FNGMEER �ave Szan AIA No.445-4073 OiSTRiCT GROUP 7VPE FIRE PROCESSEDBv p
tzemp�ion, you should become �u6ject to �he Workeri ONST. ZONE F-
Compensation provisions of the Labor Code,you must forth- V
ADDRE55 3�.4 N. First, Arcadia a W
wi�h comply wilh such provisions or this permit shall be p_
daemed revoked. TE�� S7ATi5TICnL CV+$SIFICATION APT. NDO, �/7
CONIRACTOR O. � Z
LICENSED CONTRACTORS OECLARATION ,i��, CtnSS NO. �'�� DWetL UNITS .
I hareby affirm that I am licenaed vnder provisions of Chapter 9 ADDRE55 AS above No5105 6 0
(commencing wi�h Section 7000)of Division 3 of Ihe Business and _ ��� B SEWER MAP
Professlons Code,and my Ilcense is in full force ond effect. Ci7v C�r�SS BK. �. VALICATION
SQ.FT. NO.OF N0.OF CHECK
litense Num6er 510560 Llc.Class B SIZE .rj 570RIE5 fAMILtES 1 pNE I
VALUATION
THE ANDEN GROU�1e 8/5/8 7 DESCRIPTION OF WORK ' NEW
Confractor f ,
ADD
❑I am exempt under Sec. 41$ SF �
AL�R <083,5A
8.8P.C.for thls rsason SLAB ONLY REPAIR � _
�1e: USE OF � � �
EXISTING BLDG. ��� ❑ �T� ��
Signature APPUCANT TE�� FINAI I • •f�,2 5
OWNER-BUILDER DECLARATION PRINT � DATE �f/�3/�
I heraby affirm tha�1 am exempf from the Contranor'i Licenae . m �-_
ADDRE55 AS above a 7�;.z J r_+
Law for the following rsason(Section 7031.5,Buainess and FINAL
�"'�ofessions Code): � � By ����•��''� 0 s�� 7�8 7
� � BUIIDING
I, as owner of Ihe proper�y, or my employees wlih ADDRE55
wages as their sole compensotion,will da ihe work and �OCALI7Y ' �
lhe sfructure is nor Imended or offerad for sale(Sectian � � �
7044,Bueiness and Professions Code). MOVING TEL.
� I,as owner of the property,om exciusively conirocting CONTRACTOR NO.
with licensed contractors lo constwc�the project(Sac- qDDRE55
tion 7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY SE7�BACK YARD HWY T�T'�p10P UNE WIDTH
I heraby affirm thm there is p construction lending agenty for FRONT �
ihe performance of Ihe work for which Ihia permit ia issuad v.l.
(Sec.3097,Civ.C.). SIDE
P.l.
lender's Name C1'f t hank
ro IOMH Ref.k
� Lender'a Address�4 a S_ F 1 ower� T„A, 9 O O�1
a.c.Feas ve,m��Fe� 63.75 ,
� I cerlify thol I hove read this application ond state that fhe Issuonce Fee 1�.5 Q LDAM P/C•
_ above informot' n is correct.1 ograe to comply wi�h all Coun�y Investiyotion Fea 74.25
ordinances State laws relating to building constroction, . Totol Fee LOMA perm.M
� and hereb thorize reprosematives of�his Coun�y to enter
� upon th - lioned property for inspec�ian pu�
SEE REVERSE fON EXPUNATORY IANGUAGE
Signotu Applimnt or Agen po
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