HomeMy WebLinkAbout0817A WCRKERS'CpMPENSA710N DECLARATION /�
I hereby affirm that I have a ce�tifica�e of tonsent�o ge�, APPLICATION FOR BUILDING PERMIT 'LJ
insure,or a certificate of Workers'Campensation Insurance,
' or a certified cop thereof(Sec.3800,Lo6.C.) �
7��WC�05-2Y79-Oglm6a�y Na��onwi de COUNTY OF LOS ANGELES BUILOING AND SAFETY
� Certifiad copy is he�eby fu��ished. FOR APPLICANT TO fILL IN 6UILDING
A�DRESS
� Carlified capy is filed wifh Ihe tounty building inspec- BUIWING 6$$ Armitos P lace
lion depariment. A�DRE55
oa�e 8/5/87 Applicam THE ANDEN GROUP a,rDiamond Bar z�P 91765 �ocr.uTr Diamond Bar
CERTIFICATE OF EXEMPTION PROM WORKERS' SizE OF LOT NOW ONLLOTS CRO55557,D1dR10I1CI B3T BZ VCI & Go lden S 111 5
COMPENSATION INSURANCE g
(This section need not be completed if the permit is for one A53ESSOR
hundred dollars($100)or less.) rRan 4 25 8 0 BLOqC lOT NO. 3 2 Nqp gpq( PAGE PARCEL
. TEI. USE ONE N�4F �7
I�ertify that in the performance ot the work for which this OwNER H NO. � � I NO. I� �`
permil is issued,1 sholl not employ any person in any monner qDDRESS P•�•B�X 33 2 9 dh„�n SPECIAL ��
so as to become subject to 1he Warkeri Compensation Laws. O°'�'�� CONDITIONS d
/^- ciTv Covina nr 91722 V
.. ie Applican� OC
.adTICE TO APPLICANT: If, after mokin �this Cerfificate of ARCHITECT OR TE�� DISTRICT GROU7 TYPE FIRE PROCESSED BY O
9 ENGINEER Dave Szan AIA No.445-4073 CONST. 20NE I--
Ezemption, you ahould become subjec� to ihe Workers'
Compensation provisions of the Labor Code,you must forth- ADDRE55 314 TI. First, Arcadia �� W
with comply with auch provisions or ihis permit shal) be 0:
deemed revokad. TE�� STATISTICAL C1A551fICA710N APT. CANDO. [n
CONTRACTOR Z
O.
LICENSED CONTRACTORS DECLARATION ���. ClASS NO. � DWELL.UNITS
I hereby offirm that 1 um licensed under proviaions of Chapter 9 ADDRESS AS above No.510 5 6 0
(mmmencing with Section 7000)of Division 3 of the Business and ��� B SEWER MAP �
Rofassions Code,and my license is in full force ond effect Ci7Y � CtA55 BK � VALIDATION
510560 B SIZEFT STOR�S 1 AMIC�IES 1 CO EK �
Licanse Number Lia Class
VAIUATION
Conrractor THE ANDEN GRO�fe 8/5/8 7 DESCRIP710N OF WORK � NEW s 7 i 2$O
462 SF ADD
❑I am exempr under Sec. GdL'd 2 q�rER ���a���A
B.BP.G.far this reason SLAB ONLY REPAIR ❑ ; �• • • • • �
�Date: -- Ez�srwc e�o�. �erao� � • •7@.2 5
SiBnofure APPLICAN7 TE�� FINAI / r x
OWNER-BUILDER DECIARATION PRINT OArE �/�j�b • c <e J(I,�J o
1 hereby affirm that 1 am exempl from the Convacror's License AS above
�w for the following reason(Section 7D31.5,B�siness and /+DDRESS p�ryp� � 0 g.� 7�8 7
ofessions Code): � !y il�ou"`�
� � BUILDING
I, as owner of the property, ar my employees with ADDRESS
wages as their sole compensation,will do the work and � � , �
�he structure is not infended or offared for sale(Section ��`��T�
7044,Businass and Professions Code). MOViNG iEl.
� I,05 owner af}he property,om a:dusively conlracfing CONiRACTOR ND. -
with licensad contractors to construcl the projecl(Sec- ADDRE55
tion 7044,Business and Vrofessions Code).
CONSTRUCTION IEN�ING AGENCY � SET�BACK YARD HWY T�tApR�.LWE WI�TH
I hereby affirm ihal Ihere is a cons�ruction lending agency for fRONi
the performance of�he wark for which Ihis permit ia iss�ed V.L. �
(Sec.3097,Civ.C.). SIDE
P.L.
Lenders Name—.�.'1t1b3rik
LDMA Ref.N
LendePaAddress�44 S. Flower. L.A. 9��71 P��•Feei PermitFae
� I certif that I have read this o Ifcation ond s�ate that the 10.5� ,
Y PP lasuonce Fae IDMA P/C M
above�information ia correct.I agree to comply with all Coumy Invsatiyo�ioa Fee �
q ordinoncea nd Stata laws relafing to building conatruclion, To�al iee 74•Z 5 LDMA Parm.k
and her authorize representatives of this Counry�o anter
� upon mentioned propeNy for inapeclian purposes.
g • � � t!t REYERS!FOR E%PIANATORY LANGIlA6!
Signature of Applicanf or Apsnl a .
� PlANS TO APPtfCANT INSPECTOR'5 NOTES OL4NiiR•11�9LUIfN Ulfl'.L;1HA7�S./,\
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