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HomeMy WebLinkAbout0808A � WORKERS'COMPENSATION DECLARATION � insorebor�ocer�ifcoreotWorkesr,Compensa;o�5e�5��a�e" APPLICATION F�OR BUILDING PERMIT - o�a certitied copy thereof(Sec.3800,Lab.C.� COUNTY OF LOS ANGELES BUILDING AND SAPETY 7�W�05-279—OQompony Natinnwirl� 2�A � Certified wpy is hereby furnished. FOR APPLICANT TO FILL IN qppRE55 ❑ Certified copy is filed with the county bvilding inspec- BUILOING �� tionf�eportment. ADORE55 679 Armitos Place �ate 8/5/87 Applicant THE ANDEN GROUP ��T� Z�P wcnutv CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF B�DGS. NEAREST � COMPENSATIONINSURANCE s�zeoF�or r,owon,�or cRosssT.Diamond Bar Blvd & Golden S ings (This settion need not be completed if Ihe permit Is for one ASSESSOR h�ndred dollars($100)or less.) rRAcr 4 2 5 S 0 B�OCK lOT NO. Mqp gpp( FAGE PARCEI TEI. 7 I tertify thaf�in fhe performance of�he work for whith this �WNER NO. _ U5� NO. '.7 permit is is5ued,I shall no�employ any persan in any manner 57ECIAL � ADDRESS P.0.B�X 3 3 2 9 CONDITIIXJS so as to become s�bject to ihe Workers'Compensation Laws. U � r�'�-�te Applicant CITV �.'OV1113 ZIP 91722 - ARCNITEC7 O TE�� DISTRICT GROUP TVPE PIRE PROCESSED BY � .JTICE TO APPIICANT: If, after making�this Cerfificate of ENGINEER `�ave Szan AIA rvo.445-4 7 � �Examption, you should become subjecf to the Workers' J �St' ��� U -Compeneation provisions of the Labor Gode,you must forth- qDDRE55 314 T7. First Arcadia C� a wiih comply 'th such pro�isians or this permit shall be 7E1. STATISTICAI QASSIFICATION APT. DO. deemed revoked. CONiRACTOR . z LICENSED CONTRACTORS DECLARATION uC C1A55 NO. � DWELL UNITS I hereby affirm�hat I om licensed�nder provisions of Ciwpier 9 ADDkESS AS above n,o.5105 6 0 (commencing with Seclion Y000)of Division 3 of ihe Business and LIC, ��R�P Professions Code,and my licanse is In full force and effect. Otv [1A55 B BK � VALIDATION SQ.f7. NO.OF NO.OF CHECK License Num6er 510 5 6 0 liC.Class B SIZE 1314 STORIES 1 FAMILIES ONE VALUATION THE ANDEN GROflD 8/5/6 7 DESCRIPTION OF WORK NE'^' Controctar `9ate App S ( 8 2 Q ��am exempr under Sec. 44 8 $F A��R ❑ , �0�'Q.$A 8.8P.C.for this reoson SLAB ONLY REPAIR = �*' ' ' ' ' � Date: USE OF DEMOL • EXISTING BL�G. � • 6$��D s� nature APPIICANT TE�. FINAL / � � . m .6 8 0 0= 9 OWNER-BUILDER DECLARATION PRiNT DATE �C � " I hareby affirm that I om exampt trom the Gonhactor's Licenae qppRE55 j'+S above FINAL �M/�� �$� 7`8 7 �Lqw for the following reason(Section 7031.5,Business and ,�.yy � i /' ofassians CodeJ: BY � �� � BWLDING I, as owner af fhe property, or my employees with ADDRE55 woges os iheir sole compensation,will do the work and ' fhe structure is nor intended or offered for sale(Sectlon �oCnuTY 7Qd4,Business ond Professions Code). MOViNG TEL. . � I,us awner o4 the prapeNy,am exdusively coMrotting ONTRACTOR NO. with licensed contractora to conetruct ihe project(Sec- qppRE55 tion 7044,Business and Profassions Code). CONSTRUCTION LENOING AGENCY �7�gq�K YARD HWV TOT PROP l NE �NIDTH I hereby affirm�ha�there is a construction lending ogency for FRONT the performance of ihe wo�k for which this permit is issued P.L. (Sec.3097,Clv.C.). SIDE v.�. Lender's Name -� �hank 5.�.5� LDMA Ref.R Lender'sAddress 444 S. FlOWEL'. L.A. 90071 P'CFee3 PermitFee � � I certlfy ihat I have reod this applicalion and stafe tbat the . Iscuonce Fee 1�.5� LDM4 P!C N � obave fnfor tion is mrroct.I agroe to comply wi�h all Counry Inveatiqanon Fw 6$.Q 0 8 prdinonc d State laws relating to building tonatruction, Total Fee � LDMA Pmm.M ond har oulhp��ze reprospntatives of�his County ro enter � upon v tioned praperty for innpaction pvrposas. � SE!lEVERSE FOR El(►UINATORY LAN6UA6E � Signorore of Appli<onr or Apenl te � : � P:AhlS TO APPLICANi Ih'SPECTOR'S hOTES ()ti�"�f i�13i�1t t)I li I)I(I.Ak 21U1�.. r. I f Fy .+ hc�. i - 4 { �. . �T . � RWurned � . .. � L�ce - t tc f II . .. �OJ1 � �PPravad --------- .--- I3�r u r nd 1 r i i n ( d l n��<h u tx h b �__.__ __�., ��� �-� r�>� �f� r� .r r I � � � ,l r l. Dmtc No � bmte � �' � - -- - ----�-_--- ,. , , --- -- ��, f , , � t p � f r � , � tl� upF!-u�t! .-1 p rrt� /(r t �f.�tr .�t - .I._-z __ �.. ._.__. �.._�_.�_—�. --- tt, t!� .-! . �<d/ .� �. t t t! p� /N ( C ___�..___._ —_ � . .. j ` ' err��, �l.a,n� r.a�:(cba/r JI( � eu N t��. 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