HomeMy WebLinkAbout0830A WORKERS'COMPENSATION DECLARATION �/'�
I hereby oHirm ihar I have a certificote of�o�,a�,�o Se�f APPLICAT�C1�1 FQR BUILDING PERMIT �
insure,or o certificale of Workers'Compensalion Insurance,
or a ceriified copy thereof�5ec.3800,Lab.C.) COUNTY aF LOS ANGELES BUILDING ANO SAFETY
7�0�1��(�05-279—O��pany NationwidP 1/C
� Cerritied copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
� Cenified copy is filed with the coue�y buiidin9 inspec- BW�DING 676 Armitos Place
tion department. ADDRE55 .
Date 8/5/87 Applicant THE ANDEN GROUP arvDiamond Bar z�v9 �ocoa�TrDiamond Bar
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF lOi NOW ON t0T5 OSSSST.D13If10I1CI $Sx' BIVCl & Golden .ci lIl S
COMPENSATION INSURANCE P 5
(This sectian need not be completed iS iha permit Is for one ASSESSOR
hundreddallars($100)orless.) TRAa42580 BLOCK LOTNO. 28 MqpBOOK PAGE PARCEL
TEL. USE ZONE �P 17,r z,.! �
I certify that�in the performance of the work for which Ihis OWNeR NO. — h�I �.p, l ! J«
parmit fs issued,I sholl nor employ any person in any monner qDDRE55 p•�•a�x 3 3 2 9 �� � SPECiAt �O',
so as to became s�bject fo Ihe Workers'Compensation Laws. (J1ti'1f CONOITIONS
�^ ciTr Covina z�P 91722 v
ib Applitanf ARCHITECTOI� TEI. �
..OTICE TO APPLICANT: If, af�er making�fhis Cenificate of ll8,V0 Szan AIA No.445-4073 DISTRICT GROUP ttvE FIRE P�toCe55eDBr p
ENGINEER
Exemptlon, you should become sv6jecl to the Workers' r CONSr. ZONE �
Campensotion provisions of the labor Code,you must forth- qDDRe55 314 N. First, Arcadia (�
with cOmply wiih such pro��sions or ihis permlt sholl be TFL, SiAT15TICAL ClAS IFICATION APT. C DO. �
deemed revokad. tn
CONTRACTOR p.
LICENSED CONTRACTORS DECLARATION �i�, CV+SS NO. a DWEII.UNI75 Z
I hereby affirm that I am licensad under provisions af Chapter 9 ADDRE55 AS above r,o.510 5 b 0
(commencing wifh Section 7000)oi Oivision 3 of Ihe Business and L�� B SEWER hV+P
Professions Code,and my license is in full force and effeci. CITY C1A55 BK � VALIDATION
510 5 6 0 B SIZEFTI5�5 5 ORI�ES 2 FAMI�LIES 1 CONE ��I
Litense Number lic.Class
ComractorTHE ANDEN GROU�1e 8/5/8 7 DESCRIPTION OF WORK NEw
VAIUATION
ADD :7�8�9 ,
❑I om exemp�under Sec. =����A
ALTER
B.BP.C,for�his reoson SLAB ONLY REGA�R ❑ s #' • • • • �
Date: USE OF DEMOL
E7(ISTING BL�G. � • r 7/1,2 S
Signature APPLICANT TE�• FINAL Z
OWNER-BUILDER DECLARATION PRINT DAiE y/�'��' . � `" ``7 4`2 5�
I hereby offirm thvt I am exempt from the Contraclor'a License }�S above
�-law for the following reason(Saction 7031.5,Business and aDORE55 FlNAL��N�� ��.� 7`8 7
, pfessions Code): � � Ey .
, �7 6UILDING
U I, as owner of fhe properly, or my employeas with ADDRESS i�
wages os fheir sole compenxation,will do the work and , ��-
the struc�ure is not intended or offered for sale(Section IOCALi7Y � . �
7044,B�siness and Profassions Code). MOVING lEl.
� I,as owner of ihe property,am exclusively controcting NTRAROR NO.
wlih Ilcansed confractora to conslruc�1he pro�ect(Sec- qDDRE55
tlon 7044,B�sinees and Professlons Code).
CONSTRUCTION LENDING AGENCY sE�BaCK YAR� Hwv �TApROTP IINE wioTA
I hereby affirm�hat there ia a conatruction lending agency for FRONT
the performance of ihe work far whicM�his permit ia iasusd P.�.
(Sec.3097,Civ.C.). SIDE
P.L.
Lende/s Name ['i t i ha n k
6 3.7 5 �^^�'Ref.x
m Lender's Address 4 4 Q S_ F 1 OW2 . T..A. 9 Q 0']1 P�C.fee S Pormit Fae �
� I tertify ihot I hnve raad ihis applicalion and state that tha lu�an<e Fee 1 O•5 O LDMH P/C k
? above informotion in correct.I agrea to comply wlih all County Investipaiion Fee ]4.Z 5
a ordinances a tale lawe reloting to building construclion, Total F�e tDMA Parm.N
R and here orize represemafivea of this County ro enter
� upon ih - �ioned property for inapection p�rposea.
� ff/f.�8'
SEE REYERSE FOR EXPLANATORY LANGUAGE
Signat�re o Applicanl or Ag�n �
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