HomeMy WebLinkAbout0810A �W'ORKERS COMPENSATION DECLARATION f'�
I here6y affirm ,�,o�� ho�e a certifica�e of�o�se�,�o self APPLICATiON FOR BUILDING PERMIT
inswe,or a cer�ifica�e of Warkers'Compensation Insuronca, �j
� or o certified copy thereof(Sec.3800,Lab.C.) �
7�WC�05-279—O�llb 2/B COUNTY OF Lp5 ANGELES BUILDING AND SAFETY
v lity o. ompany Nati Onwi dP
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN AD RE55
� Certified topy is filed with the couMy building inspec- BURDING
tiondepnrtment. ADDRESS 687 Armitos Place
oa�e 8/5/87 qpplicam THE ANDEN GRODP arv 'am nd B z�P �ocnurv d B
CERTIFICATE OF EKEMPTION FROM WORKERS' NO.OF BLDGS. ' NEAREST
COMPENSATIONINSURANCE � SIZEOF�OT NOWONtOT CROSSST.(�ldlllOhCl Bar BIVC� & Golden S rings
(This section nead nat be Completed if ihe permit is for one ASSESSOR
hundred dollars($100)or lass.) 1RACT 4 2 5 8 0 BLOCK lOi NO. fJvLp gpqC PAGE VARCEI
, 7E1. U4 v'�- Mqp
I certify Ihat in ihe performante of Ihe work for which ihis OWNER NO. — �,p,
permit is issued,I shall not employ any person in any manner qDDRE55 P.�.B�X 3 3 2 9 l SPECIAL �,
so os to 6ecome subject to the Workers'Compensalion Laws. �'y CONOITIONS 0
/�. CITY Covina ZIP 91722 V
�� -+e Applicant ARCHiTECT OR TE�� DISTRICT GROUP ttPE FIRF 7ROCESSED BV �
. .aJTICE TO APP�ICANT: If, affer making�this Certificme of ENGINEER Dave Szan AIA No.445-407 CONST. ZONE �
Exemp�ion, you should become aublec� to the Wo�kers' V
Compensafion provisions of Ihe Labor Code,you must forth- qpppE55 314 N. First Arcadia �� W
wllh comply wrth suth provisions or this permil shall. be TEL. STATISTICAL IXASSIFlCATION AP7.' CON�O. N
deemed ravoked. CONTRACTOR . ` �
LICENSED CONTRACTOR$DECLARATION ���, QA55 NO. � OWELL.UNITS
I hereby affirm ihat I am licansed�nder provisions of Chopter 9 ADDRE55 AS above No.510 5 60 �yER MAP
(commencing with Secfion 7000)of Division 3 of�he Business and ���,
Professions Code,and my license is in full force and effect. CITV CLA55 B BK � VALIDATION
510 5 6 0 B sae�1314 sTORs 1 �i°Es 1 CONEK
License Number Lic.Class
�� VALUATION
Con+ractor THE ANDEN GROf�1e 8/5/8 7 DESCRIPTION OF WORK Ap t 6�$2 0
�I om exemp�under Sec. � , �0 8 1.0 A
ALTER
6.8P.C.for this reason SLAB ONLY REpq�g � S �• • • • • �
Date: u5E OF oerna ❑ I • .6&p 0
exisnn�c s�oc.
Si nature APVLIUNT TE�� fINAI 2
9 OWNER-BUIIDER DECLARATION PR�NT OATE � �✓ � � ° m 6�.O O c=i
I hereby affirm that I am ezemp�from the Contrac�or'a Licensa aDozE55 AS above FINAI
�,,1pw for Ihe following reason(Section 703I.5, Business and ��� 7��i 7
. �fessions Code): N � 8Y� � <�y�
. � BUIL�ING
1, as owner of the property, or my employees wilh ADORE55
wages as�heir sole compensation,wili do the work and i��t� '
the str�cture is hot intended or offered for mle(Section
7044,Bosiness and Professions CodeJ. � MOvnvG TEL.
� I,as owner of ihe property,am exclusively contracting CONiftAC70R NO.
with licensed comractors lo construct Ibe project(Sec- qDDRE55
tion 704<,Business and Professions Code).
CONSTRUCTION LENDING AGENCY SE�BAc.Pc �ARD HWY TOTAp E�T�iINE WIDTH � .
1 hereby affirm that Ihere is a cans�ruction landing agency for FRONT
the parformonce of Ihe work for which Ihis permi�is issued P.L. -
(Sec.3097,Civ.C.). SIDE
v.i.
Lender'sName �'ltlbdl'1]S
5 7.5 0 �nn�r`RaF.w
Lender's Address 4 4 4 S. F 1 ower. L.A. 9 0 0 71 P.C.Fee f ae�m��F.e '
� 1 certify ihat I have read this opplication ond state that fhe iasuance Fee LDA1A P/C N
� a6ove inform ' Is correct.I agree�o comply with all Counry Invseligallon Fee 6$.�Q
q ordinancas d te laws reloting to building consiruction, Tolal Fme IDMA Germ.If
and here a arize representnfives of fhis Counfy fo enter
� upon h - tioned property for inapectiqn urposee.
^ Q Q SEE REVENSE FOR EXPIANAiORY LANGUAGE
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