HomeMy WebLinkAbout0800A WORKERS'COMPENSATION�ECLARATION f'�
I hereby of4irm 7hat I have a cerlificate of�o�5a�„o ge�f APPLICATI�N FOR BUILDING PERMIT � �
insure,or a certificate of Workers'Compensation Insurance, L�
` or o certified cop thereo4(Sec 3800,�ab.C.) (,�UNTY OF LOS ANGELES BUILDING AND SAFETY
7���05-2�79-0¢0 6a�y Na ;onwi d z�B
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUItDING
ADDRE55 (7 Illl
� Cerrified copy is filed wiih the county building insPe�- BU4DiNG 670 Armitos Place
tion department. ADDRE55
Dale 8/5/87 Applicant THE ANDBN GROUP c�rrDiamond Bar z�r 91765 �ocn��rv Diamond Bar
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF 8tDG5. NE4RE5T
COMPENSATIONINSURANCE SiZEOFLOT NOWONLOT cRosssr.Diamond Bar BIVC; & Golden S ings
4This sedion need no1 be tomple�ed if Ihe permif is for one ASSESSOR
h�ndred dollars(E�00)or Iess.) TRncr 42580 BIOCK lOTNO. 26 �y�qp gpp�( PAGE PARCEL
TE�' USE ONE �P
I cer�ify iho�in the performonce of the work for which this Own7ER THE AND NO. � NO. �
permit is issued,I sholl not emplay any person In any manner P.Q.$Q$ 3 3 2 9 f SPECiAI � ��
so as to become 6ubject to the Workara'Campensatian Lawe. A�� UD� CONDITIONS �
CITY Covina Z�p 91722 � V
�nle Applimnt d'
ARCHIiEG7 OR iEL•
....IDTICE Tp APPUCANT: If, afte� meking�lhis Certi{imte of ENGINEER Dave Szan AIA No.445-4073 DISTRICT GROUP TYPE FIRE iROCE55ED6Y O
Examption, you should become eubject �o Ihe Workers' CONST. ZONE I—
Compensation provisions of the Lobor Code,you must forth• qpDRE55 314 N. First, Arcadia l I� W
with comply with such provislons or Ihis permit shall ba � 7EL STATISTICAI CIASSIFICATION ` APT. CONDO. a
deemed revoked. CONTRACTOR HE NDE RO o. �
tICENSED CONTRACfORS DECLARATION ���, CLA55 NO. � DWEII.UNITS Z
I hereby affirm Ihat I am litensed under provisions of Chapter 9 ADDRESS AS above No.510 5 60
(commancing with Sectio�7000)of Division 3 of the Businass and ���, ��R M�P
Profassions Code,and my license is in full force and effect. UN Cl/a55 B eK � YALIOATION
510 5 6 0 B SQ.EFT 5 ORI�ES F MItOIES �- CO EK
Litense Number lit.Class
VALUATION
Cantracto.THE ANDEN GRO[�1e 8/5/8 7 DESCRIPTIpN OF WORK 3 �1 A D Q S 6�8 2 0 �"0 8 0,0 A
�I am exempt under Sea GdYd 2 SF' q�TER ' �r• • ` •�' �
8.8P.C.for this reason SLAB ONLY REPAIR � I ••6&0 0
USE OF
Date: E%ISTING BLDG. ���
Signafure APGUCANT TEL. FINAL �. o • •6�;.U�}�
OWNER-BUILDER DECLARATION PRiNi �� DATE G/y �� O a.� 7"H 7
I hereby affirm that I om ezempt from the Contractor's Licensa }�S above
�.—Low for the following reason(Seclion 7031.5,8usiness and /oDRE55 p�Np� n
�ofessions Code): N � By .l�sv� -
• � � BUILDING
I, os owner of fhe properly, or my employeas with ADDRE55
wages as their sole compensa�ion,will do the work and . � . -
Iha str�cture is not intended or offared for sole(Section IOCALITY . . .
7044,Business ond Professions Code). 7u�OVING iEl. � �-
� I,as owner of the properly,om exclusivaly contraclfnq GONTRACTOR NO.
with licensed controcton�o construcl the pro�ect(Sec- qppRE55
tion 7044,Business and Profeaslons Code).
CONSTRUCTION LENDING AGENCY SE�BACK YAR� HWY T�ApROP.LINE WiDTH
I heieby affirm that ihere is a construction lending agency for FRONT �
the performance of the work for which Ihis permi�is issued P.l.
($ec.3097,Civ.C.). 9DE
P.L.
LendeisNama Citibank
LDMA Ref.M
m Lander'a Address�4 4 S. F 1 Ower, L.A. 9 0 0 71 P•C.Fee: Pormif Fee 7.5� '
� I cenify that I have read rhis application ond awte ihat Ihe Issuance Fee LDMA P/C k
� above informafion is correcf.I agrea to tomply wilh all County I�vasrigafion Fee
$ ordinance d State laws relating to building constroclion, To�al Pee 6 B•�� LDMA Perm.N
ond her uthorize representatives of this County�o enter
upon - entioned propeny for inspactian p�rposes.
F �� ?�%[J/p / SEE REVERSF�ON EXPIANATORY LANGWGi
Signmura ol Applimnt or Agent rpote—�
. � � PLA#!S Tq APPLICl�NT _ INSPECTOB'S NOTE5 011'M1I�.H RUI1.Ui It lli.�l'.I.r\R\I lO,ti
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