HomeMy WebLinkAbout0836A —"WORKERS'COMPENSATION DECLARATION �I
I hereby affirm tha� I have o cerlificafe of�o�$e��,o self APPLICATION FOR BUILDING PEttMIT �
insure,or a certifitate of Warkers'Compensation Insuronce,
� or o certified copy thereof(Sec.3800,Lab.C.) 1�C COUNTY OF LOS ANGELES I BUILDING AND SAFETY
7y���'yQ�5-279-00���,,,y
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUI�DING
ADDRE55
� Cerlified copy is filed with the county building inapec• BUILDING
tiandepartmenf. ADDRE55 669 Armitos Place
Date 8/5/8 7 Applicanr TH • AND .N rROUp ur ziv �pcauT�r
CERTIFICATE OF EXEMPTION FROM WORKERS' - NO.OF BiDGS. NEAREST
COMPENSATIONINSURANCE SIZEOFLOT NOWONIOT CROSS$TD1dIi10I1CI Bar $�.VCl & Golden S ings
(This secfion need no�be complefed if the permii is for onc TRAQ - ASSESSOR
hundred dollars($100)or less.) 8 Q B�OCK LOT NO. Nqp B�OK PAGE PARCEL
��� USE ZON P
I certify�hot-in the performance of the work for which this �✓NER — b�� NO. 1 ��
permit is issued,I shall not employ any person in any mpnnar �p�,. SPECIAI
so os to become Su6jecl to the Workers'Compensation Laws. ADDRE55 P•�.B�X 3 3 2 9 a U�C� CONDITIONS �
�'e APPlicant . CItY Covina nP 91722 � �
ARCHITECT TEI. �ISTRICT GR4UP TYpE FIRE GROCESSED BY
JiICE t0 APPLICANT: If, oftar making�this Cartificata of EnIGwEER °�ave- Szan pi1A No�445-407 �
Exemption, you should become aubject to tha Warkers' � ON57. ZONE U
Compensatioo pravisions of the Lobar Code,you mwt fonh• qpDRE55 314 N. First Arcadia �� W
with comply with such provisions or this permit ahall be � d�
deemed revoked. • TE�� STATISTICAL C1A551FICATION APT. DO. Z
CONTRACTOR O. /��
LICENSED CONTRACTORS DECLARATION ���, CtA55 NO. �"'V DWELL.UNiTS .
I hereby affirm that 1 am licenaed under piovisions of Chaptar 9 ADDRE55 AS above No510 5 6 0
(rnmmencing with Seclion 7000)of Division 3 of fhe 6usiness ond . 41C_ `�'ti'ER Ni4P
Profeuions Code,and my licensa is in full force and effetl. CITY C�ASS B �K � VALIDATION
License Number 510560 �i.FT. NO OF NO OF CHECK �
lic.Closs B SI2E 15 3 5 STORIES Z FAMIlIES 1 ONE
V/UtJATION
ConhactorTHE ANDEN GROU�fe 8/5/8 7 DESCRIPTION OF WORK ' NEW
418 SF ADD : �
❑I om exempt under Sec. � �
AITER �p 8 3 6 A
B.BP.C.for Ihis roason SLAB ONLY RFPAIR ❑ : �'�
DCtO: USE Of OEMOL ' ${� • • • • �
E%ISTING BLD6. ❑
SignotUre APFUCANT TE�• FINA! � •"0 7�2 Jr
OWNER-BUILDER DECLARATION � PRiNT DATE C� ?'a� �
. 1 hereby offirm that I am�xempt from the Coniractar's Ucenx A S above � ° �7�,2 5�
r,,,L,aw for the fo�lowing reaso�{Section 7031.5,Business and A�DRESS FINAL y��
� bfessiona Code): - �y ,i,�/{�,r2s"` 0 E,� 7�8 7
JBUILDING
I, as owner of the proparty, or my employees wlih ADDRE55
waqe�os their sole mmpensatipn,will do Ihe work ond «A 1TY . �ii � .
iha sfructure is not intended or offered far sale(Section i
7046,8usineas and Professions Code). MOVING TEL. I
� I,oa owner of ihe properfy,am exclusively mMracting CONTRACTOR NO. ,,
with licensed contratlars to constroct the project(Seo- qDDRE55 'I
�ion 704d,Bosiness and Pro4essions Code). ,
� REOUIRED TOTAI SETB '�.
CONSTRUC?ION LENDING AGENCY �T gq�K YARD HWY �ROV.uNE WIDTH '��
I hereby affirm thot the�e is o conshuction lending agency for PRONT I�
the performance of�he work fo�which this permit is iswed P.i. -
(Set.3097,Civ.C.}. SIDE
P.l. I
Lender'sNome_ �'iti}-ianlr
m IDMA Ref.N
m P.C.Fee S � Parmif Fee 6 3.7 rJ '
Lender'sAddressdd4 S_ Flnwar� T _A_ A(1Q']1 1�.50 '��
� I certify that I have read this application ond atate that Ihe leauonce Fee IDM,�P/C Y
a6ove infor � n is torrect.I agree b comply with all Counry Invea�igonon Fee 7 4.Z 5
ordinonce State lowa relating l0 6uilding construction, To�al fee LDMA Perm.M
and her h rize representaiivea of ihis Counry�a enter
� up o nad proparty for inspection p�rposes. li
M1 / � �e SEE REVfFR3E FOR EXPIANATpRY LANGt1AGE �
Siqnowre Applicanf or Agent I
I
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