HomeMy WebLinkAbout0839A �" WCRKERS'COMPENSATION DECLARA110N �
I hereby affirm ihat I have a certificate of consenf to self API'LICATION FOR BUILDING PERMIT
inwre,'or a certificale of Workers'Compensation Insurance,
or o ce.tified copy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
7�ofrTC�05-279—OO�lm�nY Nationwide 1/A
� Ceraified copy is hereby furnisMed. FOR APPUCANT TO FILL IN BUIIDING
nooRess 6 m'
� Certified copy is filed with ihe couny building inspec- BUIIDING
fiondeportmCnl. � ADDRE55 685 AYmitos P1aC2
oofe 8/5/87 ApplitoM THE ANDEN GROUP arrDiamond Bar z�r91765 �ocaurrDiamond Bar
CERTIFICATE OF EXEMP710N FROM WORKERS' NO.Oc B�o�S. N�+REST
COMPENSATIONINSURANCE S�ZEOFLOT NOWONlOT cRosssr.Diamond Bar BZVC� & Golden SP ings
(This section need not be completed if tbe permit is far one TRAc�4 2 5 8 0 eiocK �or NO. 5 ASSESSOR
hundred dollars(E100)or less.) MAV BOOK PAGE PARCEL
TEI. U ZON E NWP ) 2
1 cenify fhat in the performance of�he work for which ihis OwNeR NO — ��! NO. 7� 'J�
permit is issued,I shall nof employ any person in ony manner qDDRE55 P•�•$�X 3 3 2 9 Odv SPECIAL �
so os to 6ecome subjea ro the Workers'Compensation Lows. CONDrtiOniS �
f'^�� . CITY Covina ZIP 91.722 � V
. e Applimnt ARCNITECT O TEL. �
� .�7YICE TO APPLICANT: If, after making�rhis Certificate of �ave Szan AIA n,o.445-4073 oiSreiCr GROur TVPE FIRE rROCESSEDBv p
NGINEER
Exemption, you ahould become aubject to �he Workers' / �T' Z�E U
Compensation p�ovisions of fha Labor Code,you must fortb- qDDRE55 314 N. First, Arcadia {�V y�
with [omply with such provisions or ihis permit shnll be TEL. STATISTICAL CL4551FICATION APT. C DO. a
deemed revoked. . Z
CONTRACfOR HE A D R U o.
LICENSEO CONTRACTORS DECLARATION ���, [LA55 NO. � DWEIt.UNITS
I hereby affirm that I am licensed vnder provisions of Chapter 9 � ADDRESS p+5 above No510 5 6 0
(commencing with Section 7000)of Division 3 of the Buainass and ��� SEWER MAP
Professions Code,and my license is in f�ll force ond effect. aTr CuSS B BK. �. VALIUATION
510560 B 5°E�1535 sTOR°s2 ,c°ii°Es 1 on�ieK
License Number Lic.Class
THE ANDEN GROU� 8/5/8 7 DESCRIMION OF WORK m• NE,n� I--1 vAWAT10N
Controctor ate ���� f ] $0 9
ADD
❑I am exempt under Sec. G3ra 2 O �'0 8 3 9 A
6.8P.C.for thia reown SLAB ONLY A`�R
REPAIR � _ #• • • • • �
Ddte: u5E OF DEMOL
E%ISTING BLDG. ❑ � •�•7 4,2 5
SiqnalVre APPLICANT TE�� FINAL
OWNER•BUILDER DECLARATION PRINT D DATE ����/�� � " °���5�
I hereby affirm that I am exempl from the Contractor's License }LS above
�law for the following reason(SQdion 70.31.5, Business and ADDReSS FINAL 0�.� �"8 7
, �fessions Code): � N � !y ��-.�'"
., '7 BUIIDING
�J I, as owner of�he property, or my employeea with qoDRE55
wages os�heir sole compansation,will do the work and �p�AUtt � � �
the srructure is not iMended m offerad for sale(Seciion�- �
7044,Business and Professions Code�. htOviNG TEL.
� I,os owner of the property,am excl�sively con}tacling CONTRAClOR NO.
with licensed conrractors 10 tonstr�ct fhe project(Sec- ApDRE55
tion 7044,Business and Professions Code).
REQUIRED TOTAL SETBA K
CONSTRUC710N LENDING AGENCY SET enCK YARD HWY p�pp,i�NE wioiii
I here6y offirm that there is a consiruttion lending agency for fRON7
ihe performance of Ihe work for which Ihis permit is issued a.L.
(Sec.3097,Civ.�.). SiDE
P.L.
Lander'sNama Citibank
LOMA Ref.M -
m lender'sAddress444 S. F10WEr. L.A. 90071 PC.FeeS a�.m�iFee '
� I certify lhaf I have reod lhis applitafion.ond btofe ihot Ihe Issuance Fee LOMA P/C N
above infw i n is correct.I agree To mmply wilh all CouMy Investigation Fee
'q ordinance an Stote Iaws relating to building tonstruciion, to�al Fee 74'•Z 5 IAMp,parm.N
$ and her y horize rapresantatives of this Counly fo enter
� u n e - entioned properly for insp fl n purposes.
^ ��D SEE REVERSE FOR E%PLANATORY LANGVAGE
Signafure oi Applicam w Agenl Dote
OW�f{t Hl'lI.UF R UI�(!_AN411LtV
p�{,(�y TO pPr�l(CF<�NT IA26P€CTdfi'S NDTfiS , �
I t ,Ly nft �r I� . ��1,
�To: �. � R�t�urtr�d . _. . � . . � ' . ...Llc f�� F.c. !rll � ,c• e,.�� '� ��i�
Approved . ._ . — $r sandtrl .u��x�( ! ��lnti�clt �anzti ! -1
Na-�... Pnte Iio D Ee .. �,��� � rcqr rr. u/ nu+1��c��n+t ! �li r:� r/ J� .,(rcb,�
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. . _� I - � � � - - . � . - . � _ - �(;�JJarehaal ,n�r�! j Jrl .ha�.rf rrt=r
-- „l1�qrJux�mpe .;lnv ��,l�,n�,rs�,/c -r� '1H1si,i,
i _ . . . Rrqui+ed i DateR¢ceived . . .- .. . . � ant'�+ppli.Nnt{ura�rrnrif�uF,jr:LctLieafplicdn(tn,�ciril
� A avais �=�N� —or Aporoved �-- . - '--� � � t' . r�/nn1 r r�fbara f�r.L e dre f�l!h�t l.'�tiUU).l.
4Q ero ftv
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��V. ( ..._. .. � .�_ . . - . . � th + u .e�s i �1 d of�.c ed to :-S,� 7044;
�ticc�.,h uap_. rn�n� � .� . ���� _ .. . . Br sr x .and P 1�c�o es�( �J� 1 hc C. t���rur s! �nse
�. —. _�...—__-,-_. �—_� . .. I.as d ��n t upph r �n u n /h P (i a J, A ilJs .
r�<.„�r,�t�,.- ,. � . —"" or a r c ah . n .1 ! r! �s 1 k f�r�!L"
� ��--- � 1f�i � �1 ! � nu•xi empZut<<.a pr�nrJ J tl,ut v� �1, �.
� �.,q pr r.n� ts t a� rL ! i�f r d�' s 1 ff
.._� .. ....� �....__ . .� . : " '' , � - . h�u e e t!e b !d n,q r j . i.n[e l�l �it! c
I C o,7 m° � - . _ r`—'"— _ • 1'P n( impl- � n -al �u�n bu�f! i17 L n tt�
bu ! I¢�ro� n,�iLal he Jrd n�,�br�.i:fJ, om[�r>e���fnr
�P=�r�a.,+K»•ae�e., �-- � . . , ' . . . th p p,sr of sale/. . .
��ence)�CancpY? . . .. .. � - '. I.asoKn<. of .��.H .pF, �„e .J.s��e�yc. .roc-
�ing w rn Ikens�.j conir�id ��fo cvnstr .h p�oi?=r5ec.
i �- �� � 70aa}&a�sine_es und Pru(c.� ��Cn,le 7be C��nrr�cn>r:r
r .�a I F.-f!on � r
� . _ h.;onry)i � I�I.�.gi l.icenac Lau Joes nnt apply�1n an���r,��rii�r qf prnpertv u'L'n
� _�� - . . . . .. hoilds nr nnprures 1/+creon,�nd iol�o�nntru.ts fur sutb
�lot Ora�naae _ . . �,r-�yertc rrith a ountructnrrsJ licencvd prr:au.xrzt tn tlre
. . . G t .tr's7 s�L.�u/. . . .
a-,rk-� . . . _ ... . . .
�� � � i om e�xe p,tinder Sre. 3-�P_C.for rh�is
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