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WORKERS'COMPENSATION DECLARATION � �
I hereby affirm thol I hove o cerlifica�e of consent fo 5e�f � APPLICATION FQR BUILDING PERMIT
insure,or a ceAificole of Workers'Compensation Insurante,
-or a certified copy�hereof(Sec.3800,lab.C.) �
73WC�Q5-279—Og16 3/B COUNTY OF l05 ANGELES BUILDING AND SAFETY
P�olicy o. ompany,_,�F3{'lnl'1Wlf3P
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUIL�ING
ADDRE55
� Ceni4ied copy is filed with the co�nty b�ilding inspec- BUILDiNG
tiondeparfineni. ADDRE55 691 ATmitos P1aCe
oare 8/5/8 7 Applitan� THE ANDEN GROUP aTv ziv �ocauTr
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEARFST
COMPENSATION INSURANCE SIZEOF LOT NOW Onl t07 cRoss sr.Diamond $1T.' $ZVCl & Golden rings
�This section need not be completed if the permit is for one tRACT 42580� e�ocK LOT NO. ASSESSOR
hundred dollarz($100)or less.) MAG BOOK PAGE PARCEL
TE�' USE ZONE MAP p -
I tertify that in ihe performonce of Ihe work for whith ihis OWNER NO. — , NO. 7� ./
permit is issued,1 shal I not employ any person in any manner qDDRE55 P.�.BQX 3 3 2 9 SVECIAL �
so as to become subject to ihe Workers'Compensafion Laws. �Q� C�NDITIpNS Q
f--�- cirv Covina nP 91722 V
8e Applimnt �
ARCHITECT OR TEI. DISTRICT GROUP TYPE FIRE PROCESSED 8Y
,�,.OTICE TO APPLICANT: If, aRer making�ihis Certificota of ENGINEER Dave Szan AIA No. — CONST. ZONE �
.Ezemprion, yoo should become subject to the Workers'
Compensa�ion provisions of tAe Labor Code,you must forth- qDDRE55 314 N. First Arcadia �V W
wilh tomply with such provisions or this permif shall 6e G..
deemed revoked. TE�� STATISTICAI ClAS51FICA710N AP7. CONDO. �
CONTRAC�OR p, Z
UCENSED CONTRACTORS DECLARATION ���, ClASS NO. DWELL.UNITS
I hereby affi�m that I om licensed under provisions of Chopler 9 ADDRE55 AS above n,o.5105 6 0 �y�R MAP
(commencing wi�h Sedion 7000)of Division 3 04 fhe Business and LIC.
Professions Code,ond my license is in full force and effect. CITY - Cu55 B � � VALIDATION
510560 B s�°ze�1409 NO.OF NO.OF CHECK
License Number Lic.Ciass STORIES 1 FAMIUES �ONE
YALUATION
Contractor T HE ANDEN GRO[}��e 8/5/8 7 DESCRIVTION Of WORK N� � S 7�2$0
�I om exempt under Sec. � ,
AUER
8.8P.C.for rhis reason SLAB ONLY REPAIR s :`=0 8 2,2 A
Date: USE OF
EJ(ISTING BI�G. DEMOL rt� �� � � 1
$ignalure AP7LICANT TE�� FINAL
OWNER-BUILDER DECLARATION PRIM pA� �?� � J o •7(�2 5
I hereby affirm that I am exempl from the Contrac�or's License
,�.law for the fo�lowing reason(Section 7031.5, Business ond a.00Re55 AS above FINAL • w •7 4.z J�c=i
' ofessions Code): euaoit�G � ey "��� 0�1 7—8 7
� � I, os owner of�he proparty, or my employees with ADDRESS
wages os their sole compensution,will do the work and ��q�ITY �
the structure is nol intended or offered for sala(Section
7044,Business and Professions Code). MpVING TEL.
� I,os owner of Ihe property,am exclVsively conirocting CONTRACTOR NO.
with licensed contractors to tonsiruct the project(Sec- qpoa455
tion 7044,Business and Professions Code).
CONSTRUCiION IEN�ING AGENCV �7�gq�K VARD HWV T�T'4�P2E�Tp �INE WIDTH �
I hereby affirm that fhera is a construclion lending ogency for. fRONT '
the periormance of the work for which this permi�is ias�ed a.l.
(Sac.3097,Civ.C.). SIDE
P.l.
Lende✓aName Citi.hgnk �
LDMA Ref.N
" 444 S. F10W2r', I�.A. 90071 PC.FeeS PormlfFea 63.75 '
' Lender'a Address
� I cartify that I have read ihis application and state�hat the iuuance Fee 1�•5� LDnM v/[M
4 ahove informati is correct.I agree lo comply with all Caunty invesfigotion Fee '
' ardinonces a ote laws relating to building COnStrVclion, Total Fee 74•25 IDMA Perm.N
R pnd hereb a� riza reprasentativas of this Counly to enfer
$ upon e tioned property for inspa i purposas.
�Q SEF REVHRSE iOR E%PIANATORY tANGUAGF
Signaturo o Applimnt or Agent pote
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