HomeMy WebLinkAbout0829A WORKERS'COMPENSATION DECLARATION . - �
I hereby affirm Ihat I have a ceriificate of�o�,e�,,a ge�f APPL�CAETION FQR BUILDI NG PERMIT
insure,or o cerfifiwte of Workers'Compenwfion insurpnce,
or o cerrified copy thereofi(Sec.3800,�ob.C.) CQUNTY CF LOS ANGELES BUIIDING AND SAFETY �
7��C�05-279-04���ny Nai-innwir3a 1/A
� Ceriified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILOING
ADDRESS
� Ce�tif+ed copy is filed with the county 6uilding inspec- BUII�ING 6$� Armitos P lace
fion deptlrtment. ADDRESS
Date 8/5/87 �Applicant THE ANDEN GROUP aTvDiam nd B r z�P �ocnurv Diamond Bar
CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BlDGS. NFAREST
COMPENSATIONINSURANCE SIZEOFtOT NOwOnIIOT cRosssT.Diamond Bar BZVCZ & Golden $ 1riJS
(This s6ction need not be completed if 1he permit is for one 7RACT 42 S H O � BLOCK lOT NO. 2 Q �ESSON
hundred dollors(SI00)or less.) MAP BOOK vAGE vARCEL
� TEL. USE NE MAP ^y 2
I certiiy thot in Ihe performonce of the work forwhich Ihis OWNER NO. — r NO. �/'J
permit is issued,I ahall not employ ony person in any manner pDDRESS P•�•B�X 3 3 29 SPFCIAL ���
so as to become subject to the Workera'Compensation Laws. CONDITIONS 0
CITY Covina ZIP 91722 V
�te Applimm d'
ARGHITECT O ��.
.qTl[E TO APP�ICANT: If, nfter makin9�fhis Cer��fimte of RDave Szan AIA r,o.445--4073 ��STR�CT GROUP C�T zONE PROCESSED BV Q�
Ezemption, you should become subject to 1he Workers' ENGMEER H,
Compensafion provisions of ihe Labor Code,you must forth- ADORe55 314 N. First, ATCdC�{11 W
wHh comply wHh such provisfons or tbis parmit ahnll be a,�
deemed revoked. tEi� STATiS71CAt C�.455iFICA710N APT. NDO. Z
CONTRACTOR O.
LICENSED CONTRACTORS OECLARATION � �i�, C1n55 n10. 'Z'� DWELL UNITS -
I hereby affirm that l am ticenxd under provisions of Chopter 9 FWDRE55 AS above No.5105 6 0
(commencing with Section 70D0)of�ivision 3 of the Busineu and , ��� SEN/ER MAP
Profassions Code,ond my license is in full force and effect. CIiV CLA55 B �K � VALIDATION
510560 B sae�1535 sTOR�s ANOn°Es �. CO EK
License Num6er Lic.Class
VAtUAiION
ComracrorTHE ANDEN GRO�1e 8I S�B 7 DESCRIPTION OF WORK � �W
41$ $F, ADD = ,
❑I om exempt under Sea z 0 Qi 2,9 A
AITER
B.BP.C.for this renson SLAB ONLY REPAIR : �1• • • •"�
Da18: USE OF DEMOL I 9.•7�l,2 S
EXISTING BIDG.
Signature APPIICANT TEL. FINAL
OWNER-BUILDER DECLARATION PR�NT � DATE ��� � `'"7 4.�5�
I hereby affirm that I om enempt from tba Coniractor's Licenao },S above
,,.-�aw for the following reason(Section 7031.5,Business and A�oRESS � FINAL �,.�� 0 8,� 7"`8�
' ofessions Code): � � Yy �Yf
� BUIIAING
I, as owne�of tha properry, or my employees with ADORE55
woges as their sole compensafion,will do the work and ��A�T� �
the alrudure is no�inlended or offered for sole(Sac�lon
�7044,Business and Professions Codej. MOVING TEL.
� I,as owner of the properfy,am ezclusively eonfreefing CONiRACtOR NO.
with licensed conrractors to construct the projeci(Sec- qoDRE55
lion 7044,Business ond Professions Code).
CONSiRUCTION IENDING AGENCY EDUIRED YARp �� TOTAI SETaA K
SEi BACK PROP.LINE WIDTH
I hereby affirm thai there is a construc�ion lending agency for FRONi � .�
the performance of the work for which this permit is issuad p.L �
(Sea 3097,Civ.C.). SIDE
P.l.
Lender's Name—�1'tlbdrik
6 3.7 5 LDMA Ref.N
m lender's Address 4 4 4 S. F 1 ower, T�,A. 9 Q 0�]1 P'C Fee E Permir Fee '
� I cerlify thot I have read this opplicafion ond state ihat the Issuance F•e � LOMA P/C M
above informofi is torrect.I ogree to comply with oll County Inves�igarion Fee
ordinances a tate laws relating to building constructio�, Totol Fae 7 Q.2'rJ IDMq perm.N
� ond hereb a orize reprasenlalives of thia County to enrer
� upon th e- tioned property for inspectio pgrposas. �
M1 v—����`v� �� SEE REVERSE fOR E%PLANATORY LANCUA6E
Signaturo af Applimnt w Agan1 j7oa�—
1'LkNS T!3 RPPLICkNT INSP@CTOR'S hYOTES Ul1''M1I R.lA9Ll)1 R 1lF.CLrAN'�110ti
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