HomeMy WebLinkAbout0837A .<, WOP,:ERS'COM�ENSATION DECLARATION � �
I hereby offirm that I hove a�e.f,t,�afe of�o�,��,,o Sa�f APPLICATION FOR BUILDING P-ERMIT
insure,br a cerfifitpte of Workers'Compensation Insurante,
� or a certified copy thereof(Sec.3800,Lab.C.)
73WC�05-279-0�17��6 1/g COUNTY OF L615 ANGELES BUILDING AND SAFETY
Pol�c o. o pany NatiOhwida
� CerriFied copy is hereby furnished. FOR APPLICANT TQ FILL IN ADDRE55
� Certified copy ia filed with the county b�ilding inspec- BUaDiNG
tiondeparfinent. AODRE55 673 AY'mitOs PlaCe
Da�e 8/5/87 Applican� THE ANDEN GROUP aTr iamond Z�P �aaurv ' m a
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF B�oGS. NFAREST
COMPENSATIONINSURANCE 5¢EOFLO7 � NOWONLOT caosssT.Diamond Bar BLVCl & Golden S rings
(ihis section need not be comple�ed if the permit is for one TRACT 4 2 58 0 BLOCK l0T NO. /�IqpSSgppK PAGE PARCEL
hundred dollars(SI00J or less.) � TE�
OWNER NO. U ZONE � Zr'
I certify Ihaf in ihe performonce of the work for whiah ihis ' r NO. ��"�✓T
permit is issued,I ahall not employ any person i�cny manner SPECinI �
ADDRESS P•O.BOX 3 3 2 9� �Dt9 a CONDITIONS
so as fo become su6ject to the Workers'Compensation lowa. U
r"-�e Applicant arv Covina z�v 91722
.OTICE TO APPLICANT: If, oftar moking�this Certifimfe o4 ARGHITECiOR TE�� �ISTRICT GROUP NPE FIRE VROCESSEDBV �OOO
Exemption, you ahould become subject lo the Workars' ENGINEER Dave Szan AIA r,o.445-40 ry$T. ONE �
Campensotion p�ovisions of the La6or Code,yo�must forfh- qDDRE55 31Q N. First Arcadia d W
wl�h comply witb such provisions or this permit shail be �'
deemed revoked. TE�� STATISTICAL C1A551FICATION APT. ONoO.
CONTRACTOR . Z
LICENSED CONTRACTORS DECLARATION � ���_ CLA55 NO. DWELL.UNITS �
I hereby affirm thof I om licensed under provi5lons of Chapler 9 ADDRE55 �1S above No.510 5 6 0 �
(commencing with Seciion 7W0)of Division 3 of the Businau and ��� ��NER MAP
Professions Code,and my license is in full force ond effect. CITY ttASS B BK � VALIpATION
510 5 6 0 B SI�ZE FT S ORI�ES F MIL�IES Z `ONEK
License Number Lic.Clas%
VALUA710N
Comracror THE ANDEN GRO[�1e 8/5/8 7 DESCRIPTION OF WORK A p ; :�O 8 3 7 A
�I am exempl under Sec. 418 $F A�.�R � , #• • � •� �
B.BP.C.for thts reoson SLAB ONLY REPAIR ❑ f I .� •7 4.2 5
USE OF
���e' EXISTING BIDG. DEMOI
Signaturo � APPLICANT TEL. FINA4 /I/�y� ��/ e m a 7 4..���
PRINT
OWNER-BUILDEB DECLARATION - DATE Y �'7 0 8,1 7-8 7
I heraby affirm�hat I am exempt from the Contractor's license pi8 above �
.Law for the following reason(Sectlon 7031.5,Business and ADDRE55 FINAL y}�
f� �ofessions Code�: sy //���x"�YZ
- J I, as owner of ihe prope�ty, ar my employees with ADORE55 •
wages as ihair sola tompensa�ion,will do Ihe work and �Q�p��ITY ,
the slrucWre is not inlended or offered for sole(Seclion
7044,Bus�ness and Rofessions Code). m�OvirlG � TEt.
� I,a5 owner Of the property,am eatlusively[anlrattlng CONTRACTOR NO.
wHh Iicensed coniroctors to consfruct tha project(Sac- qDDRE55
tian 7044,8usiness and Professians CodeJ.
CONSiRUCTION IENDING AGENCY SET�BACK YARD HWY TOTApROP L�NE WIDTFI
1 hereby affirm that there is o construction lending aqency for FRONi
the pe.formonce of the work fo�which this permit is iasued v.i.
(Sec.3097,Civ.C.). SIOE
P.L.
lender'sName Citihank
6 3.7 5 �on�v.acr.�r
m Lendai s Address 4 d L{ S. F 1 OWPY� T..A. �Q Q 7], P'��fee S Permit Fee ,
� I tertify that I ave read ihis applimtion and stafe Ihat the Iasuan<e Fee ��•5 Q LDAhA P/C N
a6ove infor ti n is mrreci.I agree ro comply with oll County Invgsiiga�ion Fee
ordinonce a State lows reloting to 6uilding construction, L To�ai Fee 74.2 rJ LDMA verm.M
and her � orize representatives of this Gaunty to enler
u on e- � ' d property for inspection purposes.
EEE REYERSE FOR EX�UINAiORY UNGUAGE
� Signature of Applicanf or Aqent o�e
� i-cANS Iq ARP1dtAldT INSPECTQR'S N07E5 Ul4'1f I{H1�13.01 1 Ui(�I.AK 11 IO'�
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