HomeMy WebLinkAbout0888A 0889A (4) � , . _ . . . . ... _. . .__ _ .. _
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WORKERS'COMPENSATION DECLARATION '�'� � ' �� •- '" �' . Z
. . . � _._..... � . . �
��;��e or�oFcertifca�leofWorkcrs'fCom�pensaion��5�',a��e` �APPLICATiON_ FOR BUILDING PERMIT �
or o certiticd copy�hereo((Sec.3800;La6.C.J� � - ' �� � ��
61WETX7993 Hartford'Group GOUNTY OF LOS ANGELES BUILDING AND SAFETY � �
PolicyNo. Company BUIIDING /
Q �Cerrified mpy is hereby furniihed. t . . � POR APPLICANT TO FIL!IN ADDRESS '� 3' �. n-�'^t�
� Cerlified copy is filed with the�ounly build'hg indpec--/' � BUILDiNG .
v ,
ro�de imen /J ADDRESS 24437 East Thunder Trail
' ` �� Diamond Bar-" -�
Dafe' ApplimM G � �r CITY ZIV .... IOGLIiY �
'' CERTIFICATE OF EXEMPTIO FROM WORKERS' �„ � ' '�' � � - NO:OF BLDGS. - --- � �- NEAREST '
� � � COMPENSATION INSURANCE' � �� SRE Of LOi NOW ON tOT CRO55 ST. �
(TBis detlion need nol be completed if the permif is for pne � 72ACT 4Z�JFIH '1 BIOCK LOT NO. /' MAP BOOK'� � - PAGf PARCEI
.hundred dollars(5100)or 1ess.) .. ,.,, -, , TEL. I)
.. , . ... �•,.. .. ,. . ... .- OWNER ' Bl"a�ll � �111� NO: ��� E �P ' /l��
I cenify that�in��6e performance ot the work for which�his ��� �� >
permit is issued,I sholl nol employ any person in any monner _ . ���A� "-- �- � - � - �Q
so'o�to become'subject to the Workers'Campensalion Laws. AD�RE55 Od� CONDITIONS
V
�.. � arr zia . �
Date ��' � ' � APPlimnl� .• .� ..., � f iEL � I
7ICE TO APPLICANT:�If, alfer-moking-�his Certificdle of ARCHRFC DiS7RiC7 GROUP ttPE._� FiRE PROCESSEDBY
1np�ion, you should becoma subject to �he Workers' �� ENGMEER NO. - COry �!�E ~
Compensalion provisions of ihe Lobor Code,�ypu mv51 Forth• qDDRE55 3990 Westerl Pl SU7 t2 ��� �� - -� - �.f-^ a
wiffl COmP�y w��h Su[h provi5ionl or ihis pe�mit sholl be- 7E1. STATISTICAL CLASSIFICATiON APT. CON00. �
deemed revoked. � ,� � CON7unCiDit � NO. - �L Z
UCENSED CONTRACTORS DEQARATION- �'� � � � - �i�, - ��CtASS NO.��-� � DWEIt.UNRS �T /
I heroby offirm that 1 am licensed under provrsioas of Chopfer 9 nooRess ��3151 Ai rwa Ave. N No. 40961� gy,�R�qP
(mmmencing with Section 7000)of Divrsion 3 01 ihe Bosiness ond . . _ _ .. .. .p�.... .� �
FroFessions Code,ond my license is in fuil foice and effeU. Ctiv C1A55 "" BK- -- �' ' - YAIIQATION -'
' �� ' Sq.FT. NO.OF NO.OF CMECK � _
�license Nomber 409610 i��.�dass� ' B -' size sroeies FAMILIES - ONE � • � �
/�jc/ v�wanoN ;�C 8 Q 8 A '
. . . .. DESCRIPTI�.JC`FM/ORK . ..� .. N� 11� �0� �
Confraclor � � Dale ADD � s ) ;;c • o .2 1
�I om e•empl under Sec. � - S1 fl �Q F8�111� .RQSI d@�1Ce -- - AITER � ��, w���
. ' s I •JLla6C
I B.BP.C,for fhis reason _ REPAiR.� � -�- � �"- : � � � �
USEOF Q + o,'-_,(!;,�?�
Dale: F%ISTiNG BLDG. DEMOI
( �� Signolure �� APCLICP.NT .. .iEL. . . . . FINAL ' .' _.. . — . O C'�O`F��7
O NER-BUILDERDECLARATI vRiNT Geor e Vedell No. H5�-�OO�'� ..DATE
I hareby offirm�hat I am ezempt from�he Con�mclor'a License pDocE55 l 1 Ai r {� HNAC � � "
Law for the foliowing reason{Section 7031.5,Business ond 7 _ _ . __
Professions CodeJ: - ' � - �- " - ' aR N dy �� _ � •
, � . BUILD'NG ' . __' ' ' "'
I, os owner o(ihe property, or my employees wfih ADORESs . � �
wages os their sole compensation,will do the work and � � :%Q��a . H .
tfie x!ructure is not inlended or ofiered for sole�Section ��`L�TM � �
' 7044,Business and Professions Code).' ' � -- MO�NG � " " " " -�� �� TEt. � � ' "- . � ' ��-e"e'� c e � �
I � CONTRACTOR NO. . . ... ' .
I,as owner ot Ihe property,om exdusively contmcting
-wiih licensed conlrotlors fo[onstruct Ihe pro�¢U�Se[• qDDRE55 � °:G E'�G
I �ion 7044,Bueiness and Pwfessions Code). .. � : �
.QEQIIIRFD IUTAL SEiBACK F M.. . 1 „�{'j.4..n S
�CONSTRUCTION LENDING AGENCY SEi BACK ��ARD �HWY PROP.LME N/IDiH ����
�. I here6y offi�m fhaf there is a construttion lending agenry for FRONT - - �. �� ' � . • �
. . . ,�- -' f� ._n
-tha periormonce of ihe work(or which�his permd is�ssued --- -P.l.�-�-� �-�- -- � - - ' ------ --�-- '- --�--"" " " ��•: ��' C�--
{Sec.3097,Civ.C.). SiDE ' ,,
� Toronto Dominion Bank - �- ``' - -
- - --
m Lender's Nome �J 7 (�' IDMA Ref.k , : � '
a 144 Sansome St.p �lll t@ JOO . ._, p,[,Fee f- J J'��- Perm��Fee �� �'J V- - --
_ , ,
= lender's Address • � ' ��
i � '_` l0•� .. � ;
� I.certify thoi I hove read ihis opplication and sia�e ihot tha . .. ... . _ .�S�vU - iesuence Fea� � - - -- iDMA P/C M- .� - '� �. � �
¢ obove iniormalian is corred.I a9ree 10 comply wilh all Coony invesrgaron fee . , . '
g ordinancee ond Slale laws rela�ing to building construciion, To�al Fee--�SS D��� - LDM11q Pe�m.X -� , . , .
�
and hereby o�ihorize�epiesen�a�ives of this Counly�o eMer ��
g upon fhe abave-men�one prop t (or InspecNen pvrposes. _ �
� _ . _ 3s'---=
//11 _ -__ .
a' � ������ " .� SEE REYERSE fOR EXPLANATORY LANGUAGE ;��-' � .- 4 ,
,_ ' .
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