HomeMy WebLinkAbout0543A 0544AWORKERS' COMPENSATION DECLARATION"
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I hereby affirm that i have r certificate of consent to Self
insure, or o certificate of Workers' Compensation Insurance,
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Plan-�;2APPLICATION- FOR
APPLICATION
Jrs
BUILDING PERMIT
or o certified copy thereof (Set: 3800, Lab. C.)
A
813- (Ft
-945-104 (Ft
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
VK
Po icy o. •Aoi
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QCertified copy is hereby furnished.
FOR APPLICANT TOFILL IN
BUILDING
- _
MROCertified copy is filed with the county building inspec-
BUILDING7A340
ADDRESS
Vi.rt—ua Buena pri�.A_a
tion department.
ADDRESS 24 4
Drive
5/29/85 ANDEN GROUP
Do1e ApphtantTHE
CITY Diamond Sar
ZIP 91765
LOCALITY Diamond Bar
CERTIFICATE OF EXEMPTION FROM WORKERS'
- - _--
NO- OF BLDGS.
NEAREST
COMPENSATION INSURANCE
SIZE OF LOT
NOW ON LOT
CROSS ST. j" QQ1 81n
ngs
(This section need not be completed if the permit is for one
TRACT 42584
06
hundred dollars ($100) or less.), ..
BLOCK
LOT NO.
MAP BOOK PAGE
PARCEL
1 certify that in the performance of the work for which this
OWNER
TEL.
NO. —
USE ZONE
MAP
NO.
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permit is issued, L shalt not employ any person in any manner
SPECIAL
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91..
so Iia to become subject toADDRESS the Workers' Compensation Laws.
.... ..
CONDITIONS
V
~
--
-
CITY Covina
ZIP 91722
W
Date Applicant -
RCHI OR
TEL
ii 'TICE TO APPLICANT: If, after making this Certificate ofARCHITECT
mption, you should become subject to the Workers
ER
_
DISTRICT
GROUP
TYPE
CO
FIRE
ZZONE
PROCESSED BY
O
V
C.O mpensation provisions of the Labor Cade, you must forth-
ADDRESS
ArCddla
rf0
46-3
to
{�`'%with
.comply with such provisions or this, permit sholl be
revoked,, .. .. „-
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- -
CONTRACTOR See Ow=
- _
TEL.
NO.LICENSED
STATISTICAL CLASSIFICATION
APL.
CON00.- --
Jdeemed
z
CONTRACTORS DECLARATION -
LIC.
CLASS IVO. DWELL. UNITS
1 hereby affirm that I am licensed under provisions of Chapter 9
ADDRESS
NO.371 580
(commencing with Section 7000) of Division 3 of the Business and
UC.
SEWER MAP
Professions Code, and my license is in full force and -effect.
..
CITY
CLASS B
VALIDATION
License Number _371580 tic. Class B
FT. NO. OF
SIZE �� STORIES
Q.
NO. OF
fAMILfES 1
CHECK
ONE
BK. PG.
VALUATION
Q 5 4,3 A
Controctor THE ANDFdd GPOJPDate" 5/29285
DESCRIPTIONOF WORK
NEW Q
$ 61r146.00 �
1 Sec.
Caar a ---
--
ADD
� , , , � 2 j
am exempt under
ALTER ❑
B.&P.C- for this reason
_
REPAIR �
f
I e 2 1 5 10
Date:
USE OF
• a 2 1 11 Q u
EXISTING BLDG.
DEMOL
.Ci,
Signature - -
-
APPLICANT
FINAL 'S
0612-85
OWNER -BUILDER DECLARATION
A
NO.
PATE J��
1 hwebriaffirm Thal f am exempt from the Cummoor'sUcense
_
20 5 [, (t A
Law for the following reason (Section 7031.5, Business and
ADDRESS
FINALg �/J�
.
".Professions Code).' _. _... _.... • . ..
...BY- f/.
4 • • •
1` 1 1, as owner of the property, or my employees with
NG
BUILDADDRE55
wages as their sole compensation, will do the work and
-
1 • .5 % G U Q
the structure is not intended or offered for sale (Section
LOCALITY
®
70", Business and Professions Code).
MOVING
TEL
• • 3 7 2 Q Q 5
I, as owner of the property, am exclusively contracting
CONTRACTOR
NO.
with licensed contractors to construct the project (Sec -44
;
G 2 _ R
0612-85
tion 70, Business and Professions Code).
ADDRESS
" `�
CONSTRUCTION LENDING AGENCY
SET BACK YED ARD- HWY
TOT SE LINE WIDTH -
-
I hereby offirm that there is a construction lending agency for
FRONT
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C).
SIDE
COntlnmtal Illimis
PL
Lender's Name
- Lender's Addres:.99 Park AVIS. i N;;'Y. 10043
- -
Rc. fee s -
-4615
COMA Ref. #
I that d his the
=Fee10
pollbove
certify ve s application and state that
inf ti is U. I agree to comply with all County
-LDMA
PEC #
Investigtion Fee
ordingn .s,g t .e elating to_bvilding, consiructign,I
Wong
and h eby r of this County to -nter
DMA Perm. #
m upon e e ent ed property for inspectio pas
o
SEE REVERSE FOR EXPLANATORY LANGUAGE
5ignatur -of Applicant or Agent to
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