HomeMy WebLinkAbout0811A 1� � _._
WORKERS COMPENSATION DECIARATION �
I hereby offirm rhot I hava a certifimfe of conseM to Sa�f APPLICATION� FOR BUILDING PERMIT
insure,or a cer�ifimte of Workers'Compensation Insurance, �
�or a certified copy thereof(Sec.3800,Lob.C.) 2/(.` COUNTY OF LOS ANGELES BUIL�ING AND SAFETY
'7Po�WCN0o05-279—OQompany NationwiAa
� Certified copy is hereby furnishad. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
� Ceriified copy is filed with rhe coumy building inspeo- BUiIDiNG
r�o�deparimen�. ADORE55 689 AL'mitos P1aCe
Date 8/5/87 qPP�i�a�� THE ANDEN GROUP c�Tv Diam IIP IOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NO oN`�or� c`ossssr.Diamond Bar BZVC�{ & Goiden S rin S
COMPENSATION INSURANCE �J
(This SeCtion need not be Completed if the pBrmit la for one TRACi 4 25 8 0 bIOCK LOT NO. MAP BpqC VAGE PARCEL
hundred dollars(E100)or lass.)
�l. U ZONE MAi 2
1 certifiy that in the performance of the wark for which this �WNER NO. — �j�+ NO. l�7�✓
pa�mit is�ssued,I shall not employ any person in any manner ADDRESS P•�.B�X 3 3 2 9 G SPECIAL O
so as to become subject lo ihe Workars'Compenwtlon Lawa. OL9�� CONDITIONS
�-. nrv Covina nP 91722 �
Y. .JTICE 70 APPLICANT•P�fiaflar moking�ihiE Cartifitote of A�HITEQOR TEL DISTRICT GROUP TYPE FIRE PROCESSEOBY O
Easmption, you ahould become subject to ihe Workera' ENGINEER Dave Szan AIA r,o.A45-407 CONST. ZONE I—
Compensation provisions of the Labor Code,you must forth- qD�RE55 314 N. F'1I'S't Arcadia �� W
wi�h comply wifh such provisions or this permif shall 6e 6:'
TEL. STATISTICAI QASSIiICATION APT. ONDO. (n
deemed revoked. CONTRACTOR � Z
LICENSED CONTRACTORS DECIARATION . �iC. C1A55 NO. � DwEll.UNITS
I hereby affirm ihot I am licensed under provisions of Choptar 9 ADDRE55 .�S ab ove n,o.51 D 5 fi 0
(tommenting with Section 7000)of Division 3 of the Busineu ond ��� B SEWER MAP
Professions Code,and my license is in full force ond effect. CiTV Cta55 BK � VALIDATION
so.F�.1314 NO.OF NO.OF CHECK
LicenseNumber 510560 tic.Class B s�ze STORIES 1 FAMIlIES 1 orie
� VALUATION
THE ANDEN GRO 8/5/8 7 DESCR�PTION Of WORK NEW
Controctor �re ; 6 8 2 0 �
ADD :�'O S 1,1 {I
�1 am exempt under Sec.
ALTER
B.&P.C.for thie reason SLAB ONLY REPA�R ❑ � #• •��� � �
Oate: E%ST�ING BL�G. DFMOL 1 p •6 8 0 0
Signolure APPUCANT TEL. FINAL • n =
OWNER-BUILDER DECIARATION PRINT � DATE � 1`3/� � m 6�O Q�
I hereby offirm that I am exempt from the CoMractor's License qODRE55 AS above �g�� '7•-8']
�ow for the following reason(Saction 7031.5, Business ond RINAL > �,y
. ��fessionsCode): � 0y d�..�
..a..
JsuaoiNc
I, as owner of the property, or my employees with ADDRESS
wages as Iheir sole compensation,will do the work and �p�q�ITV '
the struc�ure is not Intended or offered for sdle(Seclian
7044,Business ond Professions Code). MOVING TEL.
� I,ps ownar of fhe property,am exdusively confmciing CONTRACTOR NO.
wlth licensed coniractars to construct thc projeu(Sec- qDDRE55
tion 7044,Business and Professians Code).
CONSTRUCTION LENDING AGENCY �7�gq�K YARD HWV TOTAPROTP LINE WIDTFI
I hereby affirm ihai thera is a construclion lending ogency for FRONT
fhe performance of the work far which ihis permit is iasued P.L.
(Sec.3097,Civ,C.). Si�[
P.L.
Lender's Nome Citi bank
IOMA ReF.M
m Lender's Address 4 4 4 S. F 1 owe r, T,.A. 9 0 0 71 P'C.Fee S Parmir Fee �
� I certify that 1 h e.read ihis application and state fhot the bsuance Pee �'�•5� �nnnn piC N
� above infwm ' is co�rect.I ogree to comply wifh oll County Investigo�ion Fee �8'Q Q
q ordinonces fafe lows reloting to 6uilding construcllon, Torol Fea IDMA perm.M
R on here reprasen�atives of this CouMy ro enter
upo �t5 - M� property for inspe io purposes. '
^ �� �Q SEE REYERSE FOR EXPLANATORY LANGUAGE
Sipnaturo of Applican�or Agent Dore
S'tAhS YO AP?LICANT INSPEC70R'S NOT&S . Ok4'!�I R Bl'll.i)I H UI(.1.'tih" 1 i(JR �
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