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Home My WebLink About0799A WORKERS'COMPENSATION DECLARATION � insure,�or�afce�ifca�eof Worke5f1Compensa�ionlnsuran e" APPLICATION FOR BUILDING � PERMIT p3��'��ge/�� b �� 2/A COUNTY OF�OS ANGELES BUIIDING AND SAFETY PolicyNo. Compony Nationwide � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUR��NG AWRESS � Certified copy Is filed with the coun�y 6uilding inspec- BUIIDING 68z Armitos Place tion depar�ment. ADDRE55 oore 8/5/87 ApplicoM THE ANDEN GROUP arvDiamond Bar z�P 91765 �ocnurv Diamond Sar CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BioGS. NEAREST COMPENSATION INSURANCE . SIZEOFLOT nIOWONLOi ceosssT.Diamond $1L' $ZVCl & Golden S rings (This setlion need not be completed if fbe permil ia fa�one ASSESSOR hundred dollars(51 DO)or less.J TRACf 4 2 5 8 0 BLOCK LDT NO. 3 Q Mqp gpOK PAGE PARCEI iEl. U$ ZON E hL4F � I certify that in the parformonce of Ihe wo�k for whith ihis OWNER NO. — � ` NQ � permil is issvad,I shall nof employ any person in ony monner P,Q.$Q�' 3 3 2 9 � ��A� �� so as lo bemme subject to fhe Warkers'Companwtion taws. ADDRESS (fi(JC� CpNDI710N5 � �,e A �icant arr Covina z�r 91722 U PP ARCHITECT OR TEL. � _.OTICE TO APPUCANT: If, offer mpking�fhis Cerfificofe of OIS7RIC7 GROUP NPE FIRE OCESSEDBY O ENGINEER Dave S2an AIA No.445-4073 Exemption, you should bacome subject to the Workers' r a ONST. ZONE U Compensotion provisions af the tabor Code,you must forth- qDDRESS 314 T7. F'1TSt� Arcadia C y� with comply with such provisions or this permit shall be TEL. STATIS7ICAL CL4SSIFICATION APT. CO DO. deemed revoked. CONTRACiOR N LICENSED CONTRACTORS DECLARATION ��. C�P,SS NO. � DWELL.UNITS Z I hereby affirm thar I am licensed under provisio�s of Chopter 9 ADDRE55 A$ above No.510 5 6 0 (commencing with Section 7000)of Oivision 3 of tha Business and �� B ��R�P � Frofessions Code,and my license is in full force ond effect. CITY CLASS BK � VALIDATION 510560 B s°�eFT1314 SORIES 1 F MI�S S CONEK License Number Lic.Class THE ANDEN GROf� 8/5/8 7 DESCRIPTION OF WORK ' NEW VAIUATION CoMractor ie ❑I om exempt onder Sec. d 4 4 8 �� :6 ' :�7 9.9 A ALTER B.BP.C.for fhis reason SLAB ONLY REPAIR � s #••• • • � Dale: u5E OF � EXISTING BLDG. DEMOt I �O •�J H,O O Signature APPLICANT TEL. FINAL �a-�- OWNER-BUIIDER DECIARATION PR�NT DATE J/�q/D �' � � �6��O O� 1 hareby affirm ihat I am exempt from�he Contractor's License �AS above �Low(or Ihe following reason(Section 7031.5,Business ond ADDeE55 fINAI � f ��i.� 7�8 7 ,� �fessions Code): N By ��n"r"' � BUILDING I, os owner of the property, or my employees wilh ADDRE55 wages as their sole compensation,will do the work and ��ITV , tha slrocrore is not�nrended or offered for sale(Section 7044,Business and Professions Code). MOVING TEL. � I,os owner of ihe property,om exclusively conlracting ��NTRACTOR NO. with licenaed contraciors to conEtroct ihe projeU(Seo- ApDRE55 tion 7044,Business and Professlons Code). CONSiRUCTION IENDING AGENCY SET BACK �AR� HWY roTApROP LINE WIOTH I hereby affirm tha�there ia a consiruction lending agency for FaONi Ihe performance of the work for whith this pe�mit is issued p.l. (Sec.3097,Civ.C.). SIDE v.i. LendeisName Citibdrik � 5•�.5� LDMA Ref.M Lender's Address 4 4 4 .S. F 1 ower. L.}L. 9 0�]1 P.C.Fee E Pormit Fee ' � I certify that 1 ha�e read this application and store that the Issuance Fee l o•5 0 IDMA P/C N above inform ' n is wrrect.I agree lo comply with all County In.ea�igae�on Fee 6$.Q O $ ordinanCes n Sto}e laws relating fo building Cpnafruc�ion, iotal Fee IDMA Perm.N and her y thoriza representatives of this County�o enter � upon t n�ioned property for impection p�rposes. . � £J�.6/�,_ � �Q SEE REYERSE FOR EXYLANATORY LANGUAGB Signorure of Applicont or Agen7 te PLAhs 70 APPt,ICANT INSPEC70R'S NOTES 01k�t'R-U1�11.17h1t I)t�:1.AHA'ilU\ �_ I n Fy rff ihct I a. e �.ir s on t .'s '�,; .. � RW�rmd � . l.lc t-, F tV e. f�II � _�_ ..��. 7071 Si ' � APprov¢d -- -. -- -.— -.— � .n!!r J vuns( ! lnr�i t� - nti�t f r�! -,- —' _'... � � �.... ho.I pntn N Dato � � re�r�r<�a J ,t! t� �1 I! � r -l�- (.1,. � '_�- _. -..-- _ .__ z ...-.-� ._.._-_.:^_. - m r I �r f 7. .� r. �u ,�. , r � . � . . � . rl �J1_,�nzJ -llrnra JY� d.r� r-. .=r r.__._._.�...._ _..�...�.. ._..._�... ._._ . --_ el el �(�_ J/ _ rr �I y, nron ,l.i� C..,�- i � �...��: � . . .. _. .� tr�e.1 rr 7.:ecve.��F.au(!,{�upt<-r))��onnr�or��rnq iufl,S�o- � r '.- __.— -,- ___.._.�__t.L..__" c.-.--.-_—..---..-..- t� n Oqn/ !U .. 3 i tl�6 .� 1 C I.- mc � �� '' . � . . . 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