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HomeMy WebLinkAbout1317A 1318A (11) WORKERS'COMPENSATION DECLARATION � � I here6y ot(irm thot I have o�e�,;f��a,a of�o�=e�,�o,e�� � APPLI��ATION� FOR BUILDING PERMIT fnsura,or a cerfifica�e of Workers'Compensatfon Insurance, � , or o cerri•a [cy�opy r e� o Sec.3j�80 Lab...C�.)�J�� COUNTY OF LOS ANGELES BUILDING AND SAFETY Pol(cy���•��ompany 7� � " � . q� ,�/ � Certified copy is hereby fur�.� � FOR APPLICANT TO FILL IN ADORE55 -�W /V' � � Certified topy fs filed wilh Ihe couny buJ'Iding inspec- gUILDING flon depariment. �i1� /J.�.D�J ADDRE55 . IOCAIITY - �•�• �Q �f��� f� � ��v NEAREST oa�eC�(�Applitanl �i20llp ��n. Diamond Bar ZiP caosssr. CERTIFICATE OF E7lEMPTION FROM WORKER$' NO.OF B�DGS. ASSESSOR COMPENSATION INSURANCE 512E OF LOT NOW ON LOT I'MP eOpK PAGE FARCEL (This section need nol be compleled if the permit is far one 40387 . x USE zoNE nwv _ � p hvndred dollars(f100)or less.) T�AR BIOCK �oT ruo. � , 3 No. ��3"1/ - TEL. � � SPECIAL I cerlify that in the perfo�mance of�he work for whith this oWNEtt The Anden GTOU NO. _ CONDiTIONS 4 permit is iesued,I shall naf employ ony person in any menner , - �iSTRiCT GROUP TYPE FlRE PROCESSED BY � so os to 6ecome s�bject fo the Workers'Compensatlon laws. ADDRESS 1 O�I4 Pc1T�CV 1CW DY'1Ve� #ZOI CONST, ZONE V cirv Covina CA ' zia 91724 `�' ���" O Date APpll�ant STATISTICALCIASSIfICATION APT. CpN . �— NOTICE TO APPLICANT: If, aRer making�this Certifitote of � ARCHITECT OR TFL - �Exempfion, yau should become subject to �he Workers' ENGINEER Pfeiler I�SSOC. NO. -$8$0 �LpS5N0.�� DWEIL.UNITS_ 4 Compensation provisions of the Labor Coda,you must for�h- qooRe55 . 1559 14. Commonwealth Ave. SEwER NJ+P � with comply wi�h svch provisions or lhis permit shall be � deemed revoked. cONitiACiOrt T}t@ Ai1dC GTOU NO. BK. PG, VAIIDATION LICENSED CONiRACTORS�ECLARATION ' 1074 PaT�CV10W DT. ���• I hereby offirm that I am litensed'under provisionz of Chop�er 9 ADDRE55 NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and Covina �CA 9172� ���' �� 3�•7� Professions Code,and my licensa is in full farce and efiect. CITY � CW55 3 1�8��.�� 371580 50.FT. NO.OF NO.OF CHECK . �� � � �2 Z l�censa Number �Lie.Class—B SRE STORIES FAMILIES oNE � , Controctor The Anden Group pa,e 8-26-86 DESCRIPTIONOF WORK N� ❑ s � • •2�0 0 ❑I am exempt under Sec. � COTISL. Ret. {i�a11S � � �� � � ° •G S�O� ALTER � FlNAL �� DATE // `� � 0$.26�86 B.BP.C,fo�Ihis reason F 8 RIOC�C COI1C. REPAtR ❑ USE OF DEMOL ❑ Date: ExtSTih�G BLDG FBINAL,ni Signature APPLICANT TEL. Y // . ' OWNER• UILD EC TI N ��M NO. _ . . I here6y affirm that I am exemp�fro the omrotror's License 1559 iV. CO O wealth Ful lerto • �1 3 1,8 A law for the following reoson(Sec 31.5,Bosiness and ADDRE55 - , �- -- �� � � � � PrOfaSSlons CodEJ: PRE NT ' ' , , DBUII�iNG , I, os owner of the property, or my employeee wilh AODRE55 � e+Tj[�']� wages os iheir sole compensaflon,wlll do the work and Ihe s}r�ct�re ie nol inlended or offered for sale(Section ����TY . . . .. . . • o e j�']5= U �7044,B�sIne53 ond Profession!Code). MOVING TEL � I,os owner of 1he property,am exclusively contracting � NTRAROR NO. . _ .. �. �e��•.�j 6 wilh Ilcensed conlractors fo eonstr�cl Ihe projecf(5ec- ADDRESS •7044,Business and Pro(esslons Code). REQUIRED TOTAL SET9ACK FROM E%IST. : "�NSTRUCTION LENOING AGENCY SE7 BACK YARD HWY pROP.LINE W�OTH , � •here is a conslroclion lending ogenty for FRONT -� � . work for which fhis permH is issued G.t. SIDF ' . P.L . .. ._. . . _ . � 2GZS � P.�.Fee S �� Permit Fee , 4� s� _ .tion and sta�e that the lieuance Fea �o tomply with all County Invesiigation Fee / �to 6uilding mnstroction, � Toral fee C7�J - � nes of this Covnry to enter _ erty for inspection purposes. � � � - � SEE REVERSE FOR El(►UNATORY UNGUAGE . .... .._. . _ . . _ . . mt Agent pme � � lo 0 ... � �.4 --'� �.l , � ^� '� ' 4 T O- w ' � �� ,� � � p P , p ' ' ,, � � Q � o� �� o � b 'O ? >' '� • It'` 'p v �C' °�• '°'' '� ° ro ?:. t+ �.. ° ' J r � J 0 � A,` , p ' n U . p' . f^ ,n O C N 9 " �p � �� p b C_ -7• C� ' � � t � � � a � is . Y.. i o � � .. � ' a f, � 1 � r. j r a � 6 � P o .r , G w [L V�� ?, � � r j� O 0 S � m � � � ' O. ' 7 O 1.�b • �v � if� �a o �O 1 `�� ^-a % c'` N " a � c-y �� � ,1 �''.� � o � � ' � - O �, �3 �' � ° � ° {; � - '^' � � �� _ �,� ' A '0 0. � �. � �m 1 7 � �� 6 r� � • r' �:. ' i �c 'c � ` . y• - -^ �-1 ' ,i � � o S� o g. •o-� Zi i a � • � a � o � e _ o '� ' f 1 i yI i.t . 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