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HomeMy WebLinkAbout0816A (4) , . WvRKERS'=SOMPENSATION DECLARATION � - �� . � � � - � � � � ����� � � I here6y affirm �hai I have a tertificate of�o�,e��,o 5e,f � - � � - APPLICATION �FOR BUILDING PERMIT insure,or o ce�tificate of Workers'Compensotion Insurance, , or o ceriiiied copy�hereof�Sec.3800,Lob.C.) 3/C COUNTY OF LOS ANGELES BUILDING AND SAFETY 7PoWYQ05-279—OOlC�omPa�Y Nationwide � Ce�tified copy is hereby(�rnished. FOR APPLICANT TO FILL IN BUILDING ADORE55 603 Pantera Drive � Certified copy is filed with the�co�nty buiiding inspec- BUIIDING " �tiondeparlment. ADDRESS 603 Pantera D Date $-5-87 � APPi;�o,,,.THE ANDEN.GROUP arr Diamond Bar ziv 91765 . �ocnuTv Diamond Sar CERTIFICATE OF EXEMPTION FROM WORKERS' - � NO.OF 9LDG5. NEAREST � COMPENSATION INSURANCE � 512E OF LOi NOW ON LOT CROSS ST. (This sedion need not be completed if tha pe�mit is(or one . n55ESSOR - . hundred dollors(E100)or less.) TRACT BLOCK LOT NO. hVtP BOq( PAGE PARCEL TEL U ONE AANP I tertify thet in the performonte of�he work�for whith this � OwtdER NO. — p�p �7 3 permit is iswed,I sholl nol employ ony persan in ony manner aoDRESS �p—� �EGAI �, — so as fo beeome subject to�he Workers'Compensalion Laws. b OO c7 cONo�7�oN5 0 ` U tfe - ApplimM � � . QTr . . ZIP - � � ARCHITEC7 OR T��• DISTRICT GROUP TYPE FIRE PROCESSED eY bTIGE TO APPLICANT: If, oNer making this Certificote ot ENGMEER NO. — � Exemption, yo� sho�ld become subject to ihe Workers' CONSi. ZONE ►— Compensotion provisions of tha labor Code,you musf forth- qDDaE55 1 �N F r� Ar- � 100b� �d �+-� with tomply witb soch provisions or this permit shatl be _ . ` � TEI. S7AT�STICAL IF�CATION APT. ONDO. deemed revoked. - CpNTRACTOR NO. Z t I C E N S E D C O N T R A C T O R S D E C L A R A T I O N � � �i C.- C 1 A 5 5 N O. �W E t t.U N I T S I here6y offirm thof 1 om licensed under provisions of Chapter 9 AD�RESS NO, ��R�P (commencing wiih Section 7000)oI Division 3 of the eusiness and �i�_ � Pro�essions Coda,and my litensa is tn full forte and effect. � - CITY - � MSS . 0K � - VALIDATION LiCens9 Number 510560 SQ.Fi. NO.OF NO.OF CHECK �Lit.Glass B SIZE � STORIES FAMIlIES 1 - ONE - -.THE [��DEN GROUP H—S—HJ DESCRIPTION OF WORK VALUATION NEW Conrmc+or Da1a � App s 7,2 8 0 �p 8 1,6 A ❑I am exempt under Sec. 462 SF A��R ❑ , #� � � � � ,� B.SP.C.for this reasan ' pEpqiq � f -- use oF I • •7 4.2 5 - Dma: - exisruac atoc. �erna ❑ SignOture - - . APPlIU1M TEL. FINAL • • •7�2 5� OWNER-BUIIDER DECLARATION PRiM A EN GROUP �� DATE �/�3/� , I herehy affirm thet I om exempf from fha Coniroctor's License As� above � ��'� �-8� � -�aw for ihe fallowing reoson(Seclion 7031.5,8usiness and ADDRESS FINAL , �tessions Code): - - -� GRESENT - - dY ��� BU�IDING 1, as owner of the propariy, or my employees.with nODRESS wages as their sola compensation,will do tha work and - -� - � � � . the strucfure is not intended or offered for sale(Setlion ����TM � � 7p44,Bvsiness and Professions Code). - �- rnoviNG - - � - TEL. • . . � 1,as owner of the property,am exdosively tonimcting CONTRa.CTOR NO. � _ . with licensed contractors to construct the project(Sec- - - ADDRE55 - � � tian 7040,0usiness ond Professions Code). CONSTRUCTION LEND�NG AGENCY- " SETOBACK ' YARD HWY TDTAp�SE�TP�INEFR M WIOTH � I hereby aHirm 1ha�Ihere is a construc�ion lending ogency for FRONT the performance of fhe work for which this permit is issued . P.L . (Sec.3097.Civ.C.). SiDE P.l. Lender's Name C1tj.F7aII1C � -� - - ' - V.C.Fee S . Permir Fee 63.75 LD"^"R�r.M lender'tAddress 4G4 S. Flower, L.A.� 90071� - , I cenif thot I hava read this a lication and stote thut the 10.5� y PP . _ lesuonce Fee IDMA P/C M . . o6ove inform n is co�ect.I ogree to comply with all County in�esi�gouon Fee ardinonces Sta�e laws relating to building tonslrudion, Totol Fee - 74�25 10�N1 Perm.N � and here y ihorize represeMatives of this Covnty 1d enfer vpo t ntloned property for insp�ejcfian purposes. O / p SEE RFVERSE FOR FXtLANATORY UNGUAGE Sgnoiure o�Appllcon�or Agem po�e �� � � -� �` �_ _.y_ r.. -' i o 0 - 'a ,,� -G'` n c� ��� —' � _ �.-- '� - �^ -^tC � �, J C . � i'� '� a ^ , �_ ,-, k� i"_. � � � rt � � � '�n " i� i' j o p y'.6 �� P n � �� ZI iu �2; d �: ' ' � T n s � D,,. 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