HomeMy WebLinkAbout0805A WORKERS'GOM9ENSA�YJ!�OECLARATION �
I hereby affirm �ha� I hove o cerrificate of consent to ge�f APPLICATION FOR BUILDING PERMIT
insure,or a certificate of Workers'Compensalion Insurance,
� or a certified copy ihereof(Sec 3800,tab.C.� �
7���Q5=279-0�� Z�A COUNTY OF LOS ANGELES BUILDING AND SAFETV
pany Aiati nnwi rla
� Certified capy is hereby furnished. FOR APP�ICANT TO FILL IN BUILDING
ADDRE55
� Certi4ied copy is filed with the couny building inspec- BUII�ING
fiondeparfineM. ADDRE55 671 Armitos PlaCe
Date R/5/R 7 Applicont THF, ANT]F.N QROUP CI7 ZIP �ocaurv Diamond Bar
CERTIFICATE OF E7(EMPTION fROM WORKERS' NO.OF BLDGS, NFAREST
COMPENSATIONINSURANCE 5¢EOF�OT NOwONLOT caosssT.Diamond Bar Blvd & Golden $ lI1C�S
(This section need not be completed if the permit is for one �u�R �
hundrBCJ dollbr5($100)O�less.) 7RACT BLOCK LOT NO. MqP BOOK PAGE PARGEL
OWNER N� _ USEZONE 7NAP �^l ?
I certify ihat�in the performance o4�he work for which this �, NO. !J
permit is issued,I shall noi employ any person in any manner qDDRESS P.0.B�X 3 3 2 9 j,10�C7 CONDITIONS �
sa as to 6ecome subject�o the Workers'Compensation Lowa. �
arr Covina ziP 91722 v
,�`^.fe APplicant ARCHI7ECTOR TEI. �
�TICE TO APPLICANT: If, cher making�this Cartificafe of ENGINEER D Ve 23T1 ASA No.445-4073 aSTRICT GROUP TVPE FIRE PROCFSSEDBY Q
Exemption, you should became subject to the Workers' CONST. ZONE E—
Compenwtion provisions of the La6or Code,you must forth- qpDRE55 314 N. First Arcadia �D W
with mmply with aoch provisions or this permit ahall ba TEL. STATISTICAL CLASSIFICATION APT. CON�O. �
deemed revoked. CONTRACTOR O. Z
UCENSED CONTRACTORS DECLARATION ���, ttASS NO. � DWEIL UNI75
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS AS above No510 5 6 0
([ommencing with$Btfion 7000)04 Division 3 af the Business and ���, SEWER Mp'P
Profassions Code,ond my license is in full force and effeU. Cliv CIASS B BK � VALIDATION
54.FT NO.OF NO.OF CHECK
License Number 510 5 6 0 LiG.Class B SIZE 1314 STORIES 1 FAMILIES ONE
� vawanoN
co�no�ro.THE ANDEN GROU��e 8/5/87 DESCRIYTION OP WORK N�"
noo s 6 8 2 0
�I am ezampt under Set. Al7ER p ' -�b�0.5 A
8.8P.C.for this reason SLAB ONLY REPAIR ❑ ; �. . . . • �
USE OF
Date: EXISTING BLDG. ���� � � •.�6��O
SignOturE APPLPRI TT TEL. FINAL � �.r�
OWNER-BUIIDER DECIARATION DATE � ��Z' + •W(�E'i.O Q�
I hare6y affirm that I am ezempt from the CoNractar's License qDDRE55 AS 3�JOV2 FINAL/y�� �
Law for the following ieason(Section 7031.5, Business and ��� ']..8']
.A"�'`�ofessionaCode�: N BY ��9���"
' � 1, as owner of�he proparty, or my employees with A�DRE55 - . . .
wagas as their sole compenwtion,will do the work and �p[ALrtv � �
the struaure is not imended or offered for aale(Seclion � -
7044,Business and Professions Code). MOVING TEI.
� I,as owner of the property,pm exclusively cOnirocfing CONTRACTOR NO.
wifh licensed controctors 10 construct fhe proj0tt(S9c- qDDRE55
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCV 5E7�BACK VARD HWY T�TApROP LME WIDTH
I hereby affirm�hat there is a construuion lending agency for FRON7
the performance of 1he work for which this parmii la issued P.L.
(Sec.3097,Civ.C.�. SIDE
P.L.
Lender'sName ritihank
5•�.5 Q LDMP.Ref.N
m P.0 Fee S Parmit Fo '
Lender's Addreaa 1}[]4 � F 1 n�aar f T._A_ 9 O O 71
� I cenify that I ve read this applicotion and state that the Issuance Fes 1.�.5� tDMA P/C N
� above inform is caroct 1 aqroe to comply with oll Counly Invesrqmion Fae 6$�Q Q
S ordinances State laws relating to bullding construction, Totnl Fee LDMn Perm.M �
R ond here thorize repreeantativee of thla Counly to enter
� upoe ih ve ionad proparty for inspacQt�ion purposes.
^ V �D (j / SEE REVERSE fOR EIIPLANATOlY LAN6l1AG!
Siynmuro of Appliwnt or Aqent �e
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