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WORKERS'COMPENSATION DECLARATION •' �
��/ I hereby affirm Ihot I have a cerlificate of wnsenl to self APPLtCATION F4R BUILDING PERMIT
, insure,br a certificote of Workers'Compensatian Insurance, � �
o.a cen�fied copy rhereot(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
7�o4dCR05-279-00�6�ny Na ionwid 2/A
❑ ADDRE55 693 Armitos Place
Cerr+fied copy is hereby furnished. FOR APPLICANT TO FILL IN
� Cerlified copy is filed with ihe couMy building inspec- BUitDING
tion department, ADDRESS
oa,e 8/5/87 Applicant THE ANDEN GROUP c�r+Diamond Bar z�v91765 �ocnurrDiamond Bar
� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BiDGS. NEARESi
COMPENSATIONINSURANCE SIZEOFLO7 NOWONLOi cRosssrAiamond Bar BLVC� & Golden S ings
(This section need nol be complefad if Ihe permit is for one TRACT4 Z.S H O BLOCK �p7 Np, �ESSOR
hundred dollors(5100)or less.) Av�V 800K GAGE PARCEL
��' UgE ZONE �
I certify thar in the performance of the work for which�his �NER N — /�� NO. f�'7.•3 G�
permit Is issued,I shall not employ ony parson in ony manner P,Q.$�}{ 3 3 2 9 �4D�� SPECIaI �
so as to become subject to the Workers'Compensation Laws. AODREu A�d CONDITiONS
/" U
a� APPi��a�r CRY Covina ziv 91722 �
ARCHITECT O TEI. �
-�.aTICE TO APPLICANT: If, affer making�fhis Cerlificote of Bave Szan AIA No!�45-4073 � oisrR�cT GROUP 7YPE FIRE Pf20CE55ED8Y
�-Exemption, you should 6acome subject to the Workars' ENGWEER CONSi. ZONE
's�Compensation provisions of the Labor Code,you must forth- qDDRE55 314 N. First,' Arcadia l a W
"with comply with such provisions or this permit shall be
deemed revoked. TE�� STATISTICAL CL4SSIFICATION qP7, ON�O. �
CONTRACfOR O, Z
� UCENSEO CONTRACTORS DECIARATION � u� CLn55 NO. � DWELL.UNiTS .
IherebyaffirmlhatlamlicensedunderprovisionsofChopter9 A�ORE55 F.S d�70V@ Na510560
� (commencing wirh Section 7000)of Division 3 af the Businass and ��� B ��R M�P
Profassions Code,and my license is in full force and effect. CITY CL455 BK � YALIDATION
SQ.fT. NO OF NO.OF CHECK �
litenae Number 510 5 6 0 �;�,Cias: B � size 1314 sroaies 1 FAMILIES 1 ave .
�'HE ANDEN GROU� 8/5/8 7 DESCRIPTION OF WORK NEw
� va�uanoN
` �ontrotto 1e ADD s 6�$z� , �
❑I om exempt under Sea GdT'a e 448 SF . � ;,-�G�� ?A
ALTER
. � B.BP.C.for this reason SLAB ONLY REPAIR ❑ ; "' a c o 0
'rt° 1
� �ate: USE Of , pE��
. EXISTING BLDG. I a e�S D Q
Signature APPLICANT TEL. FlNAL /
� � OWNER-BUILDER DECLARATION PRiN7 DATE 7 �� �� � • ��U;��O� �
f hereby affirm�hat I am exempr from the Conrracror's License AS above
rnw for the following reason(Section 703I.5, Business and A�ORe55 FINAL ,r � (j F � ']�-�']
° desslons Code): 6� /``j�2�^` '
- -� I, as owner of the property, or my employees with ADDRE55 �
- . wages as rheir sole compeosalion,will do the work and '
the struclure is nat intended or offered fw aole($ection lOCnlliv
7044,Business ond Professions CodeJ. MOVING TEI.
� I,as owner of ihe property,am exclusively contracting CONiRnCTOR NO.
with licensed contractors to construc�fhe project(Sec- qooRE55
tion 704a,Business and Professions Code).
REQUIREO TOTAL ETBA K
CONSTRUCTION LENDING AGENCY SET BACK YARD HW1' pROP.LINE W�DTIi
I hereby aftirm that there is a constr�Uian lending agency for FRONT
Ihe performance of the work for which this permil is issued P.L.
(Se[.3097,Gv.C.). SIDE
P.L.
� LendeisName�lt.lbdI1�S
Lender'sAddress444 S. Flower. L.A. 90071 P���F°°x a,,,.,�rc�e57.50 �DMARef.N
� I certify thot I hava read this applimrion ond state thal the lamance Fee�-0.5� IDMA P/C N � .
above informati is corretl.I ogree to comply with all County Investigatio�Fee
$ ordinancea ate laws relafing to building conatrucfion, Toiol Fee 68.�Q IDMA Perm.N
and hara6 au 'ze representativea of this Counry io enter
^ upon - d property for inspectipn�/
U/
SEE REVERSE fOR EXRANAJORY LANGUAGE
Signat�re of Applicon�or Ayent fe
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RLANS TO AP?IiCANT INSPECTOR`SflDTES 041'til 12 la(.17I,Uf R UI�.CLANA IlUt
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