HomeMy WebLinkAbout0828A WORKERS'COMPENSATION DECIARATION f'�
I hereby affirm �hat I hove a cerrificar�e of�o�se�„o sa�f APPLICATIDN FOR �BUILDING PERMIT LI
insure,or a certificote of Workers'Cam ensorion Insurance,
• or a certified copy thereof(Sec.3800,Lo6.C.J
7�o�IC�05-279-00�6Po�Y Nationwide 1�B COUN7Y OF LOS ANGELES BUILDING AND SAFE7Y
� Certified copy is hereby 4urnished. FOR APPLICANT TO FILL IN ADDRE55 686 Armitos Place
� Certified copy is filed with Ihe muMy building inspec- BUitDING 686 Armitos Place
fion deparfinent. ADDRESS
Date��r��„87 �ApplicoM mvc+ nnln�nr r_onUp CITY ZiP �OCqLITY
CERTIFICA7E OF EXEMPiION FROM WORKERS' NO,OF BlDGS. NEAREST
COMPENSATION INSURANCE SIZE OF tOT NOW ON LOT cRoss sr.Diamond Bar a1VC�{ & Golden S ings
(ihis seciion need not be completad if the permit is for one TRACI, B�OCK � �0T�,p ASSESSOR
hundred dollars(T100)or le�s.} M.4P 8001( PAGF PARCEL
iEL. U ZONE AMP f r�
I certify thaf in fhe performance of the work for which ihis OWNER NO _ ` p�p, �
permi�is issued,I shall not employ any person in any manner ADDRE55 GO J SPECIAL � �
so as fo bacome aubject lo the Workeri Compensation Lows. CONDITIONS �
U
r-le Applicanl CITY ZIP �
ARCHITECT OR TEI.
ATICE TO APPUCANT: If, after making�ihls Cerfificate of � DISTRICt GROUP OPNST. ZONE PRqCESSE�BY �
.Exempiion, yo� ahould become subject to the Workers' ENGINEE2 No.
C2fmpensation provisions of tbe labo�Code,you must forth- qDORe55 Arcadia `� Uy,�
with comply wifh such proviaions or ihis permii aholl be p�
T��� STATIS11CAl CL4551FICATION • APT. ON00. fn
deemed revoked. CONTRAC70R p. q � Z
LICENSED CONTRACTORS DECLARATION �i�, CIASS NO. �'"v OWELL UNITS -
I hereby offirm Ihat I om licensad under provisions of Chapfer 9 ADDRE55 No. 10 5 6 0 ��R�P
(commencing with Section 70W)of Division 3 of the Business ond ���. B
Professions Code,and my license is in full force and effacf. CIlY MSS BK � VALIpATION
. S0.FT. NO.OF NO.OF CHECK
� license Number 5.l.n.g6� lla Closz R S¢E STORIES FAMIlIES ONE
YALUAiIQN
Contratror,",�,�jF �NT1FN C.RCIf[gl+a R/5�R 7 DESCRIPTION OF WORK N� : •�i$�9
�I am exempf�ndar Sac.
418 SF ADD , =:082SA
ALTER
B,BP.C.for thia reason REPAIR = �° '�' � ' �
Oa18: USE OF DEMtlI I • •7 G,L J`
EXIS7ING 6LDG.
Signatura APPLICAN7 TE�. FINAI ,y�/ • c =
' OWNER-BUILDER DECLARATION � � PRiNT DATE S�� �O �7��2�U
I hereby affirm ihat I om exempt from rhe Coniranar's License qDoaE55 AS above ��T 7"8 7
�Low for the following reason(Secfion 7031.5,Businees and FINAL y���J
�� �fassiona Code): euaoiN� B� "� ��
� I, os ownar of the properfy, or my employees with A�DRE55
woges as their sole compensatian,will do the work und ���ITY '
�he st�ucture is not INended or offered for aole(Section
7044,Business and Professions CodeJ: MOVING TEL.
� I,as owner of the property,am ezclusively comracting CONTRACTOR NO.
wifh�icensad contractors to consiruct iha project(Sec- qDDRE55
tian 7044,Business ond Professions Code).
CONSTRUCTION LENDING AGENCY SET�&4CK YARD HWY T�TApR�LINE W�DTFI
I hereby atfirm Ihat Ihere is a tonstruttion lending a9e^�Y f�� FRONT
the performance of ihe work for which this peimit is issued P.t.
($ec.3097,Civ.C.). SIDE
P.L.
Lender's Nome
IDMA Ref.8
P.G Fee$ Permi�iee ,
ie�da:5 r�ad,au-�444 5. .,� T „ 0 0 0 71
� I certi that I have read thiz o licmion and state�hat 1ha 1�.5�
tY PP luuonce Fee LDMA G/C M
' obove informatian is mrrect.I agree to comply with oll County Investigauon Fee
'� ordinances State laws relating ro 6�ilding conshucfian, ToMI Fee 7�"25 IDMA Perm.k
'� and hera a thorize representatives of thia Coonty to en�ar
� upon t o v entioned proper�y for inspecti n urposes.
� ��/� �� SEE REYERSE FOR E%PIAHATORY IANGUAGE
Siqnmuro of AppHcan�or Aga�� pota
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