HomeMy WebLinkAbout0831A WORKERS'COMPENSATION OECLARATION � �� �"
I hereby offirm tha11 have a certificate of�a�se�<<o self APPLICATION FOR BUILDING PERMIT �]
insure,or o certifimle of Workers'Compensolion Insuranm,
� or o certified copy Ihereof(Set.3800,Lab.C.J COUNTY OF LOS ANGELES BUILDING AND SAFETY
73�1i�'yRgS-279—OOc7a�ao�r�iati�nwi�e 1/A
� Cerified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRES$
� Certified copy is filed wllh the co�nty building inspec- gUILoiNG
tiondeportmenL ADDRE55 668 ALmitos P1aCe
ome 8/5/87 Applitanl THE ANDEN GROUP ar ziv LOCAU7Y D1dR1ORC� Baz'
CERTIFICATE OF EXEMPTION FROM WORKERS' ND.OF BLDGS. NEAREST
COMPENSATIONINSURANCE SIZEOFIOT NOWONIOT CROSSSTDI3ITIOTICI Bar BZVCl & Golden S ings
(This section need not be completed if the permit is fo�one rRnR4 2 5 80 BLOCK LOT NO. �ESSOR
hundred dollars�$100)or less.) �P�� vAGE PARCFL -
TEL. USE ZONE NJ+P
I certi4y that�in the performance of the work for whith thie �WNER N — � �'7�+3
permif is iuued,I shatl nof employ any penon in any monner qDDRE55 P•Q•B�X 3 3 2 9 � � SPECtAL O
w as to become subjeci ta the Workers"Compensotion Laws. J CONDITIONS
CITY Covina ZIP 91722 V
/�`�':Ye Applimnt ARCHITECT O TEL. �
�OTICE TO APPUCANT; If, oflar makin �this Certificafe of DIS7RIC7 GRQUP IYPE FIRE ROCESSED 8Y
9 ENGINEER 3Ve Szan AIA No445-4073 0
Exemptian, you should become subjecf to ihe Workers' CONST. ZONE . U
Compenwtion provisions of the La6or Code,yo�must forth- qDDRE55 314 N. First. Arcadia � W
with compiy wlih such provisions or this parmlt shall be d�
deamed revoked. . T��� STATIS71CAl QASSIfICATION APT. DO. Z
COMRACTOR p,
LICENSED CONTRACTORS DECLARATION ���, QASS NO. � �WELt.UNrtS
I hereby affirm thot I am litensed�nder provisions of Chapter 9 ADDRE55 P.S above No510 5 6 0
(commencing with Seclion 7000)of Division 3 of the Busineas ond ��� B ��R�P
Professions Code,and my license is i�full force and affect. CiTv Cuss VALIDATION
$p.FT. NO.OF NO.OF CHECK BK� �''
License Number 510 5 6 0 � i;�.qas, $ SIZE 15 3 5 STORIES 2 FAMIliES 1 ONE �
VAtUATION
6ontroaorTHE ANDEN GROU��e 8/5/8 7 �SCRIPTION OF WORK NEw
❑I am exempt under Sec. 418 SF
noo s �'809 :08'al A
ALiER #• • . • s�.
B.&P.C.for�his reason SLAB ONLY �p��R f ''
Date: E%Si�ING BLDG. DEMOL ❑ ( 7 4.2 5
Slgnature APPLICAN7 TEL. FINAI • n s.7�.�5`s''
OWNER-BUILDER DECLARATION PRiNt - DATE � ��� ��1 7,,,,8 7
I hereby affirm that I am exampt from ihe Contractor's License AS dk10Ve
�aw for the following reason(Section 7031.5, B�siness ond ADDRe55 FINAL /f
����ofessions Code): � 6y �Gh-!�.�"'�.
� BUILDING - �
I, as owner of Ihe properfy, or my employees with ADDRE55
wages as iheir sole mmpensation,will do the work ond `�AL1TV , ,.� � � - �
ihe slructure is not intanded or affered for sale(Section
7044,B�siness and Professions Code). MO�wG 7Et.
� 1,as owner of ihe property,am ezclusively tontratting CONTRACTOR NO.
with licensed con�ractors to constr�cl Ihe prolect($ec- a�oRESS
�ion 7044,Business and Professions Code).
CONSiRUCTION IENDING AGENCY REQUIRED �yqRD HWY TO7AL SETBACK .
SET BACK PROP.tINE WIOTH
I hereby pffirm Ihpl there is o consfruction lending ogency for FRONT
the performante of ihe wo�k far which this permit is issued P.L.
(Se[.3097,Civ.C.). SIDE
P.l.
Lendei s Nome C i}j ha nk
LDMA Ref.8
" Lender's Address�14 4 S. F l ow r� T..A. 9 0�71 P c.F°°E Permif Fee 6 3.7 5 ,
� 1 cerfify that I have read this application and state ihot the hsuance Fee 1�.5� IDMA P/C M
above inform 'on ia correct.I ogree to tomply with all Couny Invesiigation Fee
ordinantez State laws reloting to buildiog conatruction, io�al fee 7 4.2 r3 IOMA Perm.N
and hera thorize representalives of�hi3 COunty to enter
� upon fh ioned proparty for inspection purposos.
r �`cJ � SEE REVERSE FOR E%KANAfORY LANGUAGE
Signarure of Applicant or Aganr p�a �
i PLANS'PC AF'PEFCANT INSF{TOR'�S NOTF5 . U41'Nl�,K-R�'lI.IJIfK Uk`-CI.AR.A I'lON
I r ,F:v nff� th�,I� ,. „p! . � ., �
To: � , Ra4arn�d - - , . � � Lic���s. �fnw �e.`�>I r,_,, u 3'� .
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