HomeMy WebLinkAbout6575AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
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Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Dote -12-1-86 Applicant THE AMEN GROUP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
N")TICE TO APPLICANT: If, after making this Certificate of
nption, you should become subject to the Workers'
npensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Cade, and my license is in full force and effect.
License Number 371580. Lic. Class B
THE. AMEN GWUP 12-1-86
Contractor Date
I am exempt under Sec.
B.&P.C. for this
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
n I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
Sec. 3097, Civ. C.).
Lender's Name Continental L1l'n`O1Ei
APPLICATION FOR BUILDING PERMIT 21
Build' l5COUNTY OF LO$ ANGELES. BUILDING AND SAFETY
FOR PLICANT TO FILL IN ADDRESS 24236 E. Sylvan Glen Road
BUILD ss 24236 E. Sylvan.Glen Road LOCALITY DiaTmnd Bar
Diam nid Bar 91765 NEAREST
CITY ZIP CROSS ST.Golden Springs
NO. OF BLOGS. ASSESSOR
SIZE OF LOT NOW ON LOT MAP BOOK PAGE I PARCEL
TRACT 43756 1 BLOCK LOT NO.
US ONE
3 MAPNO.
TM AMEN GRDUP No. 967-9541
y
OWNER s CONDITIONS
ADDRESS P•O,BOX 3329
Covina
DISTRICT GROUP TYPE FIRE
COpl.
PROCESSED BY
CITY ZIP
ARCHITECT OR TEL
ENGINEER NO -
STATISTICAL CLASSIFICATION , %
CLF,aSS NO. 19-1Z_DWELL. UNITS_
APT. CO
ADDRESS -314 N. First, Arcadia SEWER MAP
M' MEN GRDUP TEL.
CONTRACTOR NO. BK. PG, VALIDATION
ADDRESS As above Uc- NO371580
VALUATION
J -Z• !
CITY CLASS B 5 a, V C! Ja 7
TSQ.
EFT.`
C CONEK
OOSTORIOES
FAMILLIIES11
OF WORK Lk NEWDESCRIPTION
GOnd.min.7-lfIT1 ADD
Units. A Sr B X s - ALTER 0REPAIR DATE s0/xf 6I ( 6 Y7-/6-9(0
USE OF
DEMOL FINAL
EXISTING BLDG. BT 6
APPLPRICANNTT THE AMEN GRDUP NO.
As above
ADDRESS
PR E
BUILDINGADDRESS 5 5 7 9 A
LOCALITY
MOVING TEL.'
CONTRACTOR NO.
ikc420G
ADDRESS
i: 4 G G i1REQUIREDTOTALSETBACKFROMEXIST.
SET BACK YARD HWY PROP. LINE WIDTH 0 09 -8 7FROM
P. I.
SIDEP. I.
Lender's Address
231 SS S. LaSalle, ago, IL 6069"P.C. Fee $ Permit Fee 2 3 f. NS 0
I certify that I have read this application and state that the N—r- Fee /Q ' TV
above information is correct. I agree to comply with all County Investigation Fee /
ordinances and State laws relating to building construction, Total Fee J Z42, 0
and hereby authorize representatives of this County to enter
up o three above-mentdioonned p-r/operty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicantant`or AgerntV Date ®s
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