HomeMy WebLinkAbout0809A -� W��k'ICERS'COMPENSATION DECIARATiON �
� I heraby affirm �ha�I have a cerliiicate of�o�,e�<<o self APPLICATION FOR BUILDING PERMIT
insure,or a certificale of Workers'Compensation Insurance,
� or a certiflad copy ihereof(Set.3800,Lab.C.) �
7��W�05-279-0��pany Nati nnwi Ae 2�C COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cenified copy is hereby 4urnished. FOR APPIICANT TO FILL IN BUIIDING
ADDRE55
� Certified copy is filed wi7h the county building inspet- BUiI�ING 683 Armitos Place
tion depa�tman�. ADDRESS
�re $�5�87 aPPu�o�� TxE ANAEN GROUP c�rvDiamond Bar nP 91765 �ocnurr Diamond Bar
CERTIFICA7E OF EXEMPTION FROM WORKERS' SiZE OF LOT n",�ow ora iors� cR�sssr.Diamond B3r $1 VCZ & Golden S ings
COMPENSATION INSURANCE
(This sec�ion need no�be compieled if Iho permit is for one TRAC7 4258 0 BLOCK LOT NO. ( �ESSOR
h�ndred dollars($100)or less.�
MAP BOOK PAGE FARCEL
iEl.
I certify that�in the performonce of ihe work for which this OWNER THE A Np. US�jON� O? t —3 r!,
��� T
permit is issued,I shall not employ any person In any monner j�,Q.$Q}{ 33 29 O� SPECIAL �
sa as to becomc subject to fhe Workers'Compenwtion Laws. ��RESS OQ�J CONDITIONS �
cirr Coviria ziv 91722
���1:e Applicam �
.O710E TO APP�ICANT: If, afror making-this Ce�tificate of ARCHITECT O TE�� DISTRICT GROua 1�'PE PIRE PROCESSED BY O
ENGINEER RDave Szan AIA No.445-4073 �r. avE H,
'Exemption, you should become su6ject to the Wo�kers' V
Compensation provisions of the Labor Code,you must forfh- qDDRE55 314 N. First, Arcadia �v �
wifh comply wifh su[h provi5ion5 or thi5 permit shall be TEL. S7ATISTICAI C1A551FICATION , APT. CONDO.
deemed revoked. � CONTRAC70R THF N o. N
UCENSED CONTRACTORS DECLARATION ���, CLA55 NO.��WELL UNITS Z
I hereby offirm thot I am licensed under provisions of Chapter 9 .n�DRESS �15 ab ove No,510 5 6 0
(commencing with Seaion 7000)of Oivisian 3 of the Business and ���. SEWER Mp'P .
Professions Code,and my license is in full force ond effed. CiTv CLASS $ BK � ' VALIDATIpN
510 5 6 0 B S ZEFT�.3 1� 5 ORI�ES 1 F MI�LIES �. CONEK
LicenseNumber Lic.Class
VALUATION
THE ANDEN GRO[bp 8/5/8 7 DESCRIPTION OF WORK "Ew
Gonlrotfor 87e App � S
❑I om ezampt under Sea GdL'd e 4 qiTER ❑ � �D 8 0�4 A
B.BP.C.for this reason SLAB ONLY REPAIR ❑ f #• � • • •1
USE Of
Dale: EXIS7ING BLDG. DE� 1 • •b&0 0
Signature APPLIG4NT TEL. FINAL /�, ��.s�-�
OWNER-BUILDER DECLARATION PRiNT DATE Y ?�/�'T' • � a C�L(}J�
I hereby offirm 1Mot I om eaempt from ihe Contrattor's Litense �:S above
�,..iaw for the follol ing reason(Saction 7031.5,Business and ADoaESS FINAI�/[ �/� ��^ � 7.-�']
bfessions Code: e By �!`�����
,�� BUILDING
I, as owner of the property, or my employees with ADORESS
wages as their sole compensotion,will do the work and ���T� '
tha sir�cture is not intended or offered for sole(Section
�044,Business ond Profeosions Code), MOv�NG T���
� I,os owner of the proparly,pm exclusively con�racting ONTRAGTOR NO.
with licansad coMrocton b consfruct ihe pro�ecf(Sec- qppRE55
tion 7044,Business and Professlons Code).
CONSTRUCTION LENDING AGENCY SE�BACK vAaD H�nn' T�TApqOR uNE WiD7Fi
I heraby affirm tha�there is a consirutlion lending agency for FROM �
�he performonce of ihe work for which�his permit is iasued P.l.
(Sec.3097,Civ.C.). SiDE
P.L.
Lende�b Name C1'tlbdrik
5.�.�O tDMA Ref,N
� 444 S. Flower, L.A. 90071 PC.FeeE PermirFas '
Lender's Address
� I cenify�hm 1 have read this appliwtion and state thot�he iasuance Fee 1 Q.�J� iDNa aiC M
obove inform 'on is correcl.I ogree to comply with oll Co�nly Inveatipo�ion Fee
'q ordinances Stole lowa relaring to building constructio�, Total Fee 6$.� LDM4 Perm.M
R and here thorize rapresantatives of ihie County�o anter
� upo v - n�ioned property for inspe��j o puprposes.
^ "'� p SEE REVERSE FOR E%P�MiATORY LANGUA6E .
Signature of Applicant o�Agenl para
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