HomeMy WebLinkAbout1317A 1318A (13) 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
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