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0746A (4)
-�,. _ _�_._ �__.. .. WORKERS'COMPENSATION bECLARATION � � +� ,,..�,�, �" ��" � � `� � � � ^ . � ' � :� .-,_ . �.-��� - :' .,,. .. I hereby offirm that i hcve o certifimie o,�o�=e�<<0 5a„ � �. � q�ap��C�TION FO�R����-BU�I�LD(N�� PERMIT���- - c s insure,or o cerrificate ot Workers'Compensahon Insuronca, L� o.a��W��ed�Cog��he��ol fs�c:38o�ationwide 2/C COUNTY OF LOS ANGELES BUILDING AND SAFETY ° U 9 U P�olicy No. . Company � . . � � � . ._ � . . . . , Cenified copy is hereby furnished. FOR APPLICANT 70�ILI(N ` ' eu�touvc ❑ AooREu 503 Dole Court Geriified copy is filed with fhe county building inspec- � BUILDING�� tiondepartmeni. ADDRE55 03 Dole Court oa�e ��8�g� ,apPuca�rTHS ANDEN GROUP ��T� Diamond Bar ZiP 91765 . iocnuTr Diamond Bar CERTIFICATE OF EXEMPTION FROM WORKERS'� � - � � NO.OF BtDGS. � NEAREST � � � � . �COAhPEN$ATION INSURANCE ��� �� - SIZE OF LOT � NOW ON LOY � � CRO55 ST. Dl"31tt011(1 �$3Y�BZVd.�GD�.C12ri S rin (This secHon need not 6e completed if ihe permii is for one T�� � eLOCK � LOT NO. . ASSESSOR � �� � � hundred dollars($700)or le£s.) MAP BOOK� � ,PAGE � PARCEL - OWNER THE�ANDEN�GROUP � TE�' � use zoNe N✓+P I certify ihot�in ihe performance of ihe work for which this� . N09Fi�=95�+1 � ���� permit is issued,1 shall not employ ony person in any manner � � SPEQAI � . �` so as to become sub'ect to the Workers'Com ADDRE55 . P,Q.. �$OX - � � �� � pensatioo Laws. CANDITIONS `a^�''fe ' n ��ca�i aTv Covina nP 91 2 U � ARCHITECi OR ' � TEL. � ..+OTICE TO APP�ICKNT�If-after makmg�this Certificate of � DISTRiCT GROUP TYPE FlRE PROCESSED BY O ENGINEER D Ve T2 NO. Exemption, you should bacome subject to the Workers' - .. _ . . .. _ - . p�\ �� CONST � ZONE i— � Compensation provisions of the Labor Coda,�you�musl forth- qDDRESS 314�N.. Fisst P.TCB[l13 9�-Q06. � �.�I(,.J � U*f\�q� O ��ph� W with comply with�such provisions or this permit shall be � � deemed revokeCJ. - � � TE�� STATISTICAL CIASSIFICATION� ��"�-� � �' APi. CONDO. coNrRAaoe THE ANDEN GROUP No ^ Z LICENSED CONTRACTORS DECIARATION - ���_� CLA55 NO. d� DWEtL UNITS I hereby offirm ihat I om licensed under proJisions of Chapier 9 AD�RE55 $g e, aS 8170VE�-- NO.- �.. -. � � (mmmencing wilh�5ection 7000)of Oivisia�-3 of the 8usiness a� ��� SEWER MAP � . . Professions Code,and my license is in fulf 4orce and effect � � � �iTy CtASS � � � -� � VALIDATION � . . . BK. PG�. SQ.FT. NO.OF NO.OF CHECK License Number � �1�$bO� ���.��a� . B SIZE 1314 STORIES"�- FAMIlIES �- ONE ��� . . �` . ' . . . n VALUATION . . . Coniracfor�� �EN �CT��.pa�e ��$�'87 DESCRIPTION OF WORN ], NEW O � 6�$2� ❑I am exempt under Sec. Gar1 0 - /+oo , ALTER � 8.8P.C.for this reason .SLAB ONLY REPAIR ❑ s oore: use oF oenno� ❑ <1?7 b 6 A � . E%ISTING BLDG. Signature � APPUU:Ni � - iEL� . . .DA E` �"' � ,�i u � #m o a a a.1. � OWNER-BUILDER DECLARATION PRiNi .THE..ANDEN GROUP NO. I hereby affirm tbat I om exempt from ihe Co.mra5tar's License � �$3�e a,S .8})OV2� - � � a o b 8,F)(j ,pd,pw for jhe following reason(Section 7031�.5,Business and AD�RESS � �a��� ofessions Code): e N n a g b 8.U 0�.�i � BUILDING �� � � � ` I, ps pwner of ihe property, or my employees with ADDRE55 �� wages'as their sole compensation,will do-the work add - ' ,�,,;,,; ��,'� 7�-8`] the slrocture is not intended or�offered for sale(Section �D�A��TY �� � � 7044,&usiness and Professions Code). MOVING TEL. � I,as owner of fhe property,am exclusively coMracting CONTRAC70R � NO. -- � with licensad con�roctors ro construct the project(Sec- � qD�RE � � �- ' �� - � �ion 7044,Business ond Professions Code). �---� � CONSTRUCTION�LENDINGAGENCY � � - SET�BACK� YARD HWY T�T pROPLWE-'�� - WIOTH I hareby atfirm that�here is a constructlon lending agency toc FRONi the performance of the work for which this permit is issued P.t. . (Sec.�3097,Civ.C.). SIDE P.l. Lander's Name r�ti�h8nk � � � -� - LDMA Ref.#1 m Lender's Address_�LF�I G_� F1 nc.�ar�. T_A_ q(1f171 P�C.fea b Permif Fae S 7.5� - ' � I certify that I have reod this applicabon and.s(ate ihqt ihe iasuance Feet�.5� LDMA P/C Y 0 above inform 'on is correcf.I agree to comply with all Counry" � in�esugonon Fee 'q ordinance 51afe laws reloting to 6uilding tonstruclion, .6 8.�� . �pMp,Perm.M $ ond her y uthorize represeniatives of this-County to�enier-�-� Tatol Fee � upon e e- ' ned propery for inspeuion orposea .. . .. .... .... .. . .. ..... .. . . ..: . . . . .. .. . . � � a g SEE4EVERSEFOR EXPLANATORYLANGUAGE � Signature o Applicanr or Agenl �e - � �"'"�'�' - � ;JLV�vt N 13 IT:.6a S E)I -.i K i 7C;M1' ��- @::aPdS T53 fiPPt!C�€'#? �� §iVS%._+'"YSR'�49TE5 .. . . � . . .� ��:. , : . ...: . .. . ..... ... . ..... : „, .m N ...;,, � ... � Y � '.'. Fr t c �c � e �.f e � a x I To: . . : '�e&urn�5 �� .. �.. . �._.� ____.. .. .______ ', s 3 e i.�� > � �f�>I� y ..:a � � . �'�"' .; . � '.J _ ! 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