HomeMy WebLinkAbout0807A "WORKEFS'COMCENSATION DECLARATION /'�
I hereby affirm �har I have o cenificate of�o�sa�„a,a�, qpp��CATION FOR BUILDING PERMIT
insure,or a certificate of Workers'Compenwtion Insuranca, LJ
ar a cenif�ed copy ihe�eof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
�v�o�c�iQ05-279—O��FPany Natinnwi�P 2/B
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADORE55
� Carrified copy is filed with�he county building inspeo- BURDi�IG
tiondeparfinenl. ADDRE55 677 AZ'mitos PlaCe
Da�e 8/5/8 7 Applim�t THE ANDEN GROUP oTrDiamond Bar z�P �ocnuTr Diamond Bar
CERTIFICATE OF EXEMP710N FROM WORKERS' SiZE OF�OT NOW ON�IOTs CROSSSST.D1dItIO11CI Bar B 1 VC� & Go lden $ 1T1 S
COMPENSATION INSURANCE �J
(This secfion need not be completed if the permit is for one rRncT42580 e�OCK LOTNO. 9 +'�ESSOR
hundred dollars(5100)or less.) MAP BOOK VAGE PAR�L
tE�" US ZONE MAP
I cenify rhm�in rhe performance of the work for which this OWNER N . — / �,q. ��'�_3
permit is issued,I sholl not employ ony person In any manner qpORE55 P•�.BOX 3 3 2 9 SPECIAt �
so as l0 6ecome subjecr to the Workers'Campensatioo Laws. LONDI710N5 �
�,�e n I�com crtr Covina zir 91722 V
� .OTICE TO APPUCANT:If tlfter mOking ihi!Certifltale of ARCHITECTO�ave Szan AIA No445-4073 DISTRICT GROUP TYPE FIRE FROCESSEDBY Q
Exemplion, you ahould become subie[t to }he Workers' ENGiNEER CONST. ZONE E-
Campensotion provisions of Ihe La6o�Code,you musf foAh- qDDRE55 314 N. First, Arcadia t� W
wi�h comply with such provisions or Ihlz permit shall be
deemad revoked. TE�� STATISTICAL CLASSIFICATION APT. CONDO. y
CONTRACTOR p, Z
LICENSED CONTRACTORS DECLARATION - ���, C1A55 NO. � OWELL.UNI75 -
I hareby affirm that I am licensed under provisions of Chapter 9 ADORE55 AS above No,510 5 6 0
(commencing with Section 7000)of Division 3 of ihe Bosiness ond ��� B ��R�P
Professions Code,and my license is in full force ond effect CI7Y CL455 BK � VALIOAiION
51Q5 0 $ s°'e� 1314 S ORI�ES 1 MI�LIES 1 CONEK
License Number �tic.Class I
VAWATION
THE ANAEN GROU� S��J�H 7 �ESCRIFrION OF WORK NEw
CoMroctor te App �6 �2�
❑1 am aaempt under Sec. . AL7ER Q , z Q Pi�,7 E{
B.BP.C.for this reason SLAB ONLY REPAiR s �
Dafe: USE OF #� • • • • �
EXISTING BLOG. DEMOI
Signa�ure � APPLICANT TEL. FINAL y I • •(�S,n O
OWNER-BUILDER�ECLARATION PR�NT DATE Y ��r/� • o o b�O O�
I hereby affirm thot I om exempt from the Co�lraUar's License AS above
�.Low for ihe following reason(Section 7031.5, Buainess and ADDRESS FINAL �
� ofessrons Code): 6y �!�<*�"'� ��i 1 7—8 7
�-.� BUILDING
I, as owner o4 ihe praperty, or my employeos with nODRE55
wages as Iheir aole compensation,will do the wo�k and �OCALITY ,
the srructure is not intended or offered for sale(Sealon
704d,Business ond Professions Code). MOVING IEL.
� I,as owner of 1hB properfy,am excl�5ively tontrocfing CONTRAC70R NO.
wilh licensed contractors fo con5lru[I fhe project(Sac- qD�RE55
tion 7044,Businass and Vrofessions Code).
CONSTRUCTION IENDING AGENCY SET�BACK YARD HWY T�T pROP.LINE WIDTFi
I here6y affirm tbat Ihere is a construction lending ogency for FRONT � -
tha performance ot Ihe work for which Ihis permi�is iuued v.l.
(Sec.3697,Civ.C.). SIOE
Lendar'sName Citib2Tlk P�
IDMA Ref.8
m �e�der's address 4 4 4 S F l owe r L A 9 0 0 71 P�� Fee E ve„��r Fse 5 7.5 0 '
� I certify Ihat I hove read Ihis application ond sfate fhat the Issuance Fae ],�.rj� LDMA P/C M
� abovg infor n is correct.I agree to comply with all Counly Invesligotion Fee
� ordinance n State laws relating to building construclion, 6 8.Q 0
R ond her y ihorize representatives of thia Co�nty to enter
Totol Fea IDMA parm,k -
� upon t e v nrioned proparty for inspect' n �rpo es.
/q i
� (l/ SEE REVERSE FOR F%PIANATORY IANGUAGE
Signalure of Appliconl or Agent D te �
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