HomeMy WebLinkAbout0818A WORKERS'COMPENSATION DECLARATION f!'�
� 1 hereby,affirm that 1 hove a.cerlificoP of mnsenl to se�� APPLI�i4��lON FOR BUILDING PERMIT `�j
insure,or a cenificote of Workers'Com ensation lasurance,
•or o cerrified copy rhereof(Sec.3800,�ab.C.) GOUNTY OF LOS ANGElES BUILDING AND SAFETY
7�o�C�05-279-0(�6��Y Na .ic�nwida 3/A
� Certified copy is hereby furn�shed. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
� Certified copy is filed wifh the county 6uilding inspac- BUiIDING 674 Armitos Place
lion deporlmBnf. ADDRESS
oare 8/5/87 qpplicam THE ANDEN GROUP cmDiamond Bar z�ag1765 �oc.ou,vDiamond Bar
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZEOf LOT ' NO orB��or� caossSST.Diamond Bar BZVCZ & Golden $ lI1 S
COMPENSATION�NSURANCE P 9
(This se[tion need no1 be completed if fhe permit is for one TRA�,4 25 8 0 BLOCK LOT NO. 2'] �ESSOIt
hundred dollors(S100)ar less.) �MP BOOK Po.GE PARCEL
TE�' U5�ZONE �-y
I certify that�in the performance of the work for which this �NER NO — p_� NO. l('
permit is issued,I shall nol employ any parson in 6ny monnar A��� P,�.gOX 3 3 2 9 ��G+ SPECIAL � �
so as fo become eu6ject to the Workers'Compensafion laws. PUD� CONDITIONS 0
c�rv Covina zia 91722 v
�^fe Applicant Lr
ARCHITECT O TEL.
� .JTICE TO APPUCANT; If, ofter making��his Cer��ficqte of �7ave Szan �I.FI r,o.445-4073 DISTRICT GROU7 �NST. ZONE PROCESSED6Y �
Exemp�ion, you ahould bacome sub�etl to the Workeri ENGiNEER I
Compenaotlon provlaions of the lobor Code,you must forth- ADDQE55 314 N. First, Arcadia `� W
wifh comply with auch provisions or Ihia permit shall be p.'
daemed revoked. TE�� STATISTICAL CLAS FICATION APT. NDO. �
CONTRACTOR O. Z
LICENSED CONTRACTORS DECIARATION �K, CU+SS NO. DWEII.UNITS -
, I hareby affirm that 1 em licensed under provisions of Chapter 9 ADDRE55 F:S above No510 5 6 0
(commenoing with Section 70W)of Divisian 3 of the Business ond . ��� SEWER MAP �
Professions Code,and my license is In full force ond effect. CITV C�A55 $ BK � VALIDATION
510 5 6 0 B SI�ZEFTZ�]O 9 STOR� 1 F MIL�IES �. CONEK �p
License Number Lic.Closs
VAGUATION �. �� . � �
6ontractorTHE ANDEN GROU�o}e S�S�S 7 DESCRIMION OF WORK � N� :7�2 8 O
❑I am exampt under Sec. Gdrd e 462 SF ADD � • t'][;.�5
SLAB ONLY A�TER • v �7 4,2 5�
8.8P.C.for this reason RE7AIR � _ �
p�re: us�oF oEMa 0&1 7�8 7
E%ISTING BLDG. ❑
Signaturo AVPLICANT TEL. PINAL �/�/_../
OWNER-BUILDER DECLARATION FRINT - DATE �D
I hereby affirm that 1 am exempt from the Contractar's License AS above
,.iaw for the following reason[Section 7031.5, Business and /+oDReSS FINAL
� �fessions Code�: � 6y ��y��
� BUILOING .
I, as owner of the property, or my employees wiih AODRE55
woges as iheir sole tompensmian,will do ihe work and ���TM , , �. �
ihe it�uclure is not intended or offered for sole(Sec}lon
7044,Business and Professions Code). nnOVWG � - TEt.
� I,os awner of Ihe property,am axclusively conirocfing CON7RACiOR NO.
with licensed coMroctors to consfruct fhe project(Seo- qDDRE55
tion 7044,Business and Vrofessions Code�.
CONSTRUCTION LEN�ING AGENCY SE7�BA�CK YARD HWY' T�T'0'pp��INE Wi�TH
I hereby nffirm fhat Ihere is a consiruction lending agency for iRONT
�he performance af Ihe work for which Ihis permit is issued p.L �
(Sec.3097,Civ.C.). SIDE
v.�.
Lender's Name �1t1b3Rk
IDMA Ref.k
� Lender'sAddress4Q4 S. Flower. L.A. 9��7]_ P�C.FeeS PermirPee 63.75 ,
� I certify that I hove read this applica�ion and state that the iasuanca Fee 1�•5 O LDNW P/C N
� a6ove inform tion is cortect.I agree to comply with oll Couny Inve�tigarion Fee ]4.Z 5
8 ordinances State laws relating to building construction, Ta1al fea LnMq Germ.N
ond here Ihorize represama�ives of this County to enter
r up n t e Mioned property for inspectiyn urp�s .
O/ / SEE REVERSE FOR ExPIANATORV LANGUAGE
Signa�un af Appl�con�or Agen� Oota
� FLANS 74 A.PPtICANT IN$P£C70R'S NDTE� . OW�Vt li lSUII.UI N UI�.('.I.AH 1 J ION
,t�affi Fn� I�. �p�.� ,��on�u .-._
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