HomeMy WebLinkAbout0806A w WORKERS'COMPENSATION DECIARATION J�
I hereby affirm thot I have a mriifimte of�o�s��,�a,��f qpp��CATION FOR BUILDING PERMIT �
insure,or a certificate of Workers'Compensation Insurance,
• or a certified topy thereof(Sec.3800,Lab.C.) z�B � COUNTY OF LOS ANGELES BUILDING AND SAFETY
7�,WC�05-279-00�mpQ�YNationwide_
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
AODRE55
� Certified copy is filed with the county 6uilding i�spec- BURDInIG 667 Armitos Place
tion departmenf. ADDRE55
Date8/5/87 ApplicontTHE ANDEN GROUP c�rfliamond Bar z�d�1765 �ocn��rrDiamond Bar
CERTIFICATEOFEXEMPTIONFROMWORKERS' SiZEOFL07 "ra°owoN`�os' cossSs,Diamond Bar BIVC� & Golden $ 1ri S
COMPENSATION INSURANCE P 9
�This sectioe need not be completed if the permi�is fo�one TRAC?�2 r'J H O BLOCK LOT NO. 14 A�ESSOR
hvndred dollars(E�DO)or less.) �P BOOK PAGE PARCEI
TEL �CC.��E �
OWNER N — "Yl' ��
I certify fhat in�he performonce of Ihe work for which ihis �L NO. "3
parmit is issued,I shall nof employ any person in ony manner qDDRE55 P•0•B�X 3 3 2 9 S?Og� �CIAL O, �
so as to becoma subject to Ihe Workers'Compensafion Laws. CONDItIONS
cirr Covina zir 91722 V
"�'�rte Applicani pC
ARCHITECT TE�• DISTRICT GROUP NPE FIRE PROCESSED BY
.pTiCE TO APPLICANT: If, after moking'fhis Certificate of ENGiNEER �ave Szan AIA Nd145-4073 0
Exemption, yo� shou�d bacame subject to fhe Workers' CONST. 20NE U
Compenwtion provisions of ihe Labar Code,you must farth- qDDRE55 314 N. First, Arcadia �(� �
with mmply with such pravisions or this permit aholl be 7EL, STATISTICAL ClAS51FICATION 1 A7T. C DO.
deemed revokad. Z
COMRACfOR NO.
UCENSED CONTRACTORS DECUIRATION �i�i Gi,45S NO.�Duveu.UNITS
I hera6y offirm tha�1 am licensed under provisions of Chapter 9 ADORE55 AS above N 05 6 0
(commencing wi�h Sec�ion 7000)ot Oivision 3 of the 8usiness and ��� SEWER MAP
Professions Code,and my license is in full force and effect. CITV Cu155 B BK � VAIIDATION
510 5 6 0 B s°e"1314 ORI�ES I. AMI�LIES 1 CONCE
License Number Lic.Class
VALUATION
ConrractoiTHE ANDEN GROU$a18 8/5/8 7 DESCRIPTION OF WORK � NEW
448SF A�� s
' Q I am e■empt onder Sec. 2 ARER � �D 8 0,6 A
B.&P.C.for this reason SLAB ONLY REPA�R = � • • • • •�
Date: USE OF DEMOL
exisnn�c e�o�. 1 • •6 8 O 0
Signature APPLICANT TEL. FINAL /
OWNER-BUIIDER DECLARATION PR�NT DATE j �T � • a ���L O O c=i
I hereby affirm�hat I am exempt from the Co�tractar's License AS above
�aw for the follawing reasan($ection 7031.5,Business and AOD2E55 FINAI �8.� 7"�i 7
�ofeuions Code): g N - by �Z���?°L�
� � BUILOING
1, as owner of the properfy, ar my employees wiih ADDRE55
woges os fheir sole compensation,wi�l do the work and - � �
the structure is not intended or offered for sale(Section ��A��T� , !�' � -
7044,Business and Professions Code). MOviNG iet.
� I,as owner of the proparty,am exclusively contracting NiRnCTOR NO.
with licenaed Con�ractors to conslruct Ihe project(Sac- pDDRE55 �
tion 7044,Business and Professions Code). -
CONSTRUCTION LENDING AGENCV SET�BACK �ARO HWY �ApROP LINE WIDTFI
I hereby affirm that Ihere is a constr�ctian lending ogancy for FRONT
the performonce of Ihe work for which this permit is issuad v.l.
(Sec.3097,Civ.C.). SIDE
v.i.
Lende�'e Name �'-�t i hank
LDMA Ref.N
m Lender's Address4 4 4 S. F 1 ower. L.A. 9���1 P�C.Fee S Varmi�Pee . ,
� I eenify that I have read this appllcmlon and state that Ihe luoance Fee 1�•5 Q LDMA P/C M
abova infor on is corract.I agree ro comply with all Caunry Inveatigatian Fee
$ ordinance a Sta�e laws relating fo building tanstruction, Total Fee 6 8.D 0 LDM.4 aerm.N
and her uthorize representativea of Ihls County to enter
� � n�a tioned proparty for inapectlon purposas.
f!!REYERS!FOR E](PLANATORY UN6UA6E
� Signawra o Applican�a Apmnl Da-�
P€ANS TO AP3'IICAkT � iNSVEtTON'S NC3TE5 U�YVI It R1�11.IH R Dh�:CI.;AR 1�tU�ti
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