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Home My WebLink About0569A 0570A (4) WORKERS'COMPENSATION DECLARATION �` t S� � I hereby affirm that I have a certifital6 Of consent�o,e�fPl� ¢3 _ APPLiCATiON� -F-O-R -BUILDING PERMIT � inaure,or a certificate of Workers'Compensotion Insurance,�eV. C � or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ��-945-104 C�P��Y Aetna Certified m is hereb furnishad. ADDkE55 24330 Vista Buena Drive ❑ PY Y FOR APPLICANT TO FILL IN � Certified copy i�filad with ihe counry 6uilding inspec- euaoiNG tion deportment. AD�RE55 24330 Vista BuPS�a DY'iVe �ocnurv Di.a[nond BaY' oate 5/29/85 qpplicant 2'HE. AI�IDEN Q�IIP cirv Diamond Bar z�r 91765 c"ossss. . CERTIFICATE OF EXEMPTION FROM WORKERS' rv0.OF BioGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAF BOOK PAGE PARCEL (This section need not be completed ii the permit ia for one TRACf 42584 USE ZONE nn^.P '^� hondred dollars(EI00]or Iess.J BLOCK LOT NO. �jQ , N . "�C/ TEI. �1 SPEGIAL I certify that in the perfamance of the work for which this ��R NO. — COtvDI710N5 pT, �permif ia issued,I sholl not employ any penon in ony monner 9 074 PdTk V1�W �1V� DISTRICt GROUP TYPE FIRE PROCESSED BY � ao as to become subject fo the Workera'Compensafion Laws. ADDRE59` � CONST. ZONE U q7Y COS71Ik3 ZIP 91722 � %F/ � Dofe App lican� STAT�STIGAI 'FIUTION qpf. C F� .NOTICE TO APFLICANT: !f,aher making this Certificate of ARCHtiECroa 7Et. �v �/ � ,mption, you should become su6ject fo the Worken' ENGINEER No. — ��p,�ryp, DWELL.UNITS � W �. �mpensation provisions of the labor Code,you muaf forth- qDDRE55 3�-4 N. 1St AV2IlU�� Cd�.� SFWER MAP � with mmply with such provlsions er this permit shall be � deemed revoked. ��' gK, p� VALIDATION � CONSRACiOR .�SE.2 �NR�S NO. . UCENSfD CONTRACIORS DECL4RATION - �i� 1 hareby aFiirm that I am licensed under proviaiona of Chap�ar 9 ADDRE55 � VAlUAT10N � (commencing with Section 700D)of Divivon 3 of the Business and �� $ 65 340.OQ Professiora Code,and my{icense is in full for[e ond effecl. CITY CLqSS S � � �c��g A SC].FT. NO OF NO.OF CHECK Licanse Number 371580 ��C� B S4ZE I � STORIES FAMIUES �- ONE �{� � � �� Com�auo� THE AI�II7IId GFd�[J��e 5/29/85 oescRirrioni oF woRK ' �+ � s �/ noo ! •2�581 ❑I am exempt u�der Sec. �r�e T�'� � ALTER � FINAL `'� • �C'�5,S�r�j B.BP.C.for this reason � OATE « 3 ��/ REPAIR use OF 0�i� c'�r S D°1°' EXISiING BtDG. �� ❑ sYµ z Q 5 7,0 A $ignoture APVLICANT hL. OWNER-BUILDER DECLARATION ��'�T NO. . #� � • • � � I hereby affirm that I am ezemp�from the Contranor's License Law for ihe following�eoson(Sacfion 7031.5,Business ond ADDRESS � � •3 9 U G D Professions Code): . �� I,as owner of the properfy, or my emplpyeas with ADOR�ES�3 ••3 9 Q 0 G c='. wages os Iheir sole compenwtion,will do tha work and `�`TM �b, C��_ the siructure is nol intended or offerad for sole(Section �W4,Business and Profeuions Code). MOVING ie�. � � I,as own0r Of the property,am exclusively confracling TRACTOR NO. ' with(icensed conlractors to constr�ct tha proiect(Sec- qppRE55 tion 7044,Business and Professions CodeJ. REQUIRED TOTAI.SfTBACK FROM EXIST. � � CONSTRUCTION LENDING AGENCY �gq� YARD HWY pRpp,lIN WIDiH � I here6y affirm fhet fhere is o tonstruciion lending agency for FRONT tha performance of the work for which this permit ie issuad p,�, (Sec.3097,Civ.C.). SipE cor��,t� ni�s P.L lender's Name ' $ 399 Park Ave., N.Y. 10�43 P.C.Fea S 2 ve,mn Fae ' Lenders Address i � I certify tha� ve re this application and stata ihat ihe Issuance Fee above info ti n is c n t.I agree ro tomply with all Counry �nreui�tion iee g ordinant an Stat la relafing to building canah cfio , Total Fee �.[�?� tl und her y thori r xnmrives of thia Coypry e r � �pon f o o rm n properry for incpecy6n ur s. //J �� SEF REVERfE FOY EXPtAXAiORY UNGUAGE , Signutur f limnt or Agent ta 0i r. �''` � .Q W N � d ?�r L� m h � m c� �. . � O„� u m v1 M-� o�.� X ��i�O .» : C a r. C �A'w C i' �'�.� t�� S � . o ,-„�.�.,�-,.o, Ay o w -�� 3 0� m�� °v3 3 M i ' O� � � O�m Ol w d O„y tl O m Y .V.�O h U�` „ .'� � O U C y L +.c. w � �,�, � ,p'.."�ymo'^ � `o ��1pE � hNtli � m •'', ��.. C � y �.� y 0 ` � v�N"Q � N ' `� C, ?�'_'+. 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