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 �
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