HomeMy WebLinkAbout0838A �'WORIEER�'COMPENSAiION DECLARA710N �
I hereby affirm ,�a�� ha�e a cerlificate of consent ta self APPLICATION FOR BUILDING PERMIT
insure,or a cerlificote of Workers'Compensotion Insurance,
•or o certified copy thereof Sec.3800,Lab.C.) �
7�C�05-2 19—OO�mpany Ndt10IIWlde l�C COUNTY OF LpS ANGELES BUILDING AN�SAFETY
Certified copy is hereby furnished. FOR APPLICANT TO FILL ADDRE55 675 ArICI1tOS P18C2
� Certified copy is filed wi�h�he couniy 6uilding inspec- BUILDING 675 Armitos Place
tion depanmeni. ADORE55
oa�e 8/5/87 Applicont THE ANDEN GROUP c�rvDiamond Bar z�v91765 ��„�,T.,Diamond Bar
CERTIFICATE Of EXEMPTION fROM WORKERS' NO.OF BLDGS. NEAREST Diamond Bar BZVCI & Golden �J' lIl S
COMPENSATION INSURANCE SiZE OF LOt NOW ON LOT CRO55 ST. p g
(This saction need not 6e compleled if the parmil is for one 1 O ASSESSOR
hundred dollprs(5100)or 1855.) rRna 4 2 5 8 0 BLpCK LOT NO. ry�qp gpq( PAGE PARCEI
O�NNER THE ANDEN GROUP i+o967-9541 u�oN� � �� ���
I certify ihal in the performance of ihe wo�k fior whith ihis .i
permit�is issued,I shall no1 employ any perwn in any manner qDDRESS P•0•B�X 3 32 9 O v COIJ�ITIONS �
ao as ta becoma sobjecf to the Workers'Compensafion laws. d,
�iTY Covina Z,P 91722 v
/���Me Applicanf ARCHIiECiO TEL �
� JTICE TO APPLICANT: If, afler making�this Certificate of ENGINEER '�ave Szany AIA No445-4073 DISTRICT GROUP �N57. ZONE ��ESSEDBY �
\ Ezemption, you shoold become subjetl to �he Workero'
Compenwtion provisions of the Lobor Code,you must forlh- qopREu 314 N. First, Arcadia l� y,�
with comply with such provisions or �his permit shall be �
deemed revoked. E� S7A71571CAL C Fi tioN AP7. C Noo.
coNtancroe THE ANDEN GROU o. Z
LICENSED CONTRACTORS DECLARATION ���, CLASS NO. DWELL.UNITS
I heraby affirm�hat I am licensed under provisians of Chapter 9 ADDRE55 AS above No 510 5 6 0
(commencing wilh Section 7D00)of Division 3 of}he BVsinass and ��� B SfWER MhP
Professions Code,and my license is in full force and effect. CITV CtA55 gK � VALI4ATION
510 5 6 0 B SI�ZEFT STORI�ES F MI�LIES �- CO EK
Litensa Num6er Lic.Class
� VALUATION
co�r.o�+o�THE ANDEN GROL�,� 8/5/87 DESCRIPTION OF WORK Sin le fami 1 "Ew � s
� Gara e ''o� ,
I am exem t under Sec.
P AITER F Q H3,8A
B.BP.C.for�his reoson SLAB ONLY REPAIR s
use oF �` #• • . . .�.
Dafe: E%ISTING BIOG. �
Signoture APPIICANT FINAL i�!/ ' • •7 4'�`5
OWNER-BUILDER DECLARATION PRINT THE ANDEN GROS�+�. pA� Cr �4-/z-��
I here6y affirm thot I am exempt from ihe Comractor's License AS above • ° "7 4'2�J`_-'
Law for ihe following reason(Section 7037.5, Business and ADDkE55 FINAL yy��i�
r�'�fessions Cade): � � By ///�'`s2y'� 0�� �"�7
' � BUILDING
I, os owner af tha property, or my employees with AODRESS
woges as their sole compensation,will do 1he work and ����Tv ,
�he structure is not imended or offered for sole(Sec�ion
7044,Business and Prafessions Gode). MOVING TEL,
� I,os owner of the property,am axclusively con}racting CONTRAGTOR NO.
with licensed comroctors to construct the proiect(Sec- qoDREss
tion 7044,Business and Professions Code).
CONSTRUCTION IENDING AGENCV SET�BACK YARD HWV �TApROP.LINE WIDTFI
1 here6y affirm ihat ihere is a cansir�clion lending ogency fo� FRONT
Ihe performonce of the work for which ihis parmit ie issued P.�.
(Sec.3097,Civ.C.j. SIDE
G.L.
lender's Name �'i ti hank
63.75 �onnn eaf.•
m Lender'a Addrass 4 4 4 S. F 1 ower. L.A. 9 0�71 P�C.Fea S Pormit Fee ,
� I mrtify thot I have read this application and atale ihat the , iuuan<a Fae �.0.5� �DhAA P/C M
obove infor tion R correct.I aqree lo comply with all County Invesuoation Fse �
$ ardinonce nd State Iews relplinp lo building[onstr�ction, iofal Fea ]4.25 lpNu1 Parm.M
R ond her awhorize reprosen�aHves of this County to enter
� u on entioned property far inspection urpo es.
� � /� S 7
tE!REVERSE FOR E%PLANATORY LAN6UA6E
SiqnaNre of Applicont or Aqenl la
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