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HomeMy WebLinkAbout06_25_1985 - 21015 PATHFINDER RD ,. ,� ,. � WORKERS'COMPENSATIONbECLARATION : . � ` � � � � ' � L�-. e �1 hereby affirm.that I have o certificole af mnsent to self . � ;�g�,a,a�a�e�,,f��a,eofWo.ka,���omPe�=„e���=�,a��e,o� APPLICAT14,1N FOR BUILDING PERN►IT . � o�tertified copy thereof(Sec.3800,lab.�C.� �� , . � COUNTY OF LOS ANG�LES ; BUILUIMG AND SAFETY � � PolicyNa . � � Company . . � :Gertified copy�s here6y furn�shed. " FOR APPLICANT TO FILL iN Bwto�NG , - . �+' A�ORESS �.��-r�: �J i.' � ..' : . �' , .� .. �:., .. .� Certified copy is filed wifh fhe county building insper BUItDING � - '-- _. - � _ tion deparfinenL . . . ADDRE55 LOCAIITY - C.. t � ,�f . . .. .. . ' .. ,.. . .._._ : � Date . . . _ ..APPliconr � - � - £��L.�,.?,r -'`'� �.. E..,",'�'�..� .. zia cRo5555L �;. .: . . , ...r-.._ �. .�. _ . : :s �f.' • ,.. � CERTIFtCATE OF EXEMPTION fROM WORKERS�' - �� � . NO.oF BLDGS.� �p � As5e550R . ;' � � �� � �� � - �COMPENSATION INSURANCE �� �� SIZE OF LO7 � NOW ON lOT �- MaP.800K � � � PAGE � PRRCEL � � 0. •--��� �.(This Se[tion need�not be�completed if Fhe perm�1�is foi one TRA�T 1 ,r••. ���:. � BLOCK-� � LOT NO. CX � . VSB ZONE OP ,'.' ';.��� � � �.�� U hundred doliars($106y or less j �� � � �� ��. . �� . . � :: W , . ` 4�;-...�.. TEl �- _ . � ;,,,� ..-^' SPECIAI . �. - .� 1�certify:thot inJMe performanca of the�work far whic6.fhia �'NER � . ivp "7/t +' � CO�vDiTiONS �� < ti, � � permH is issuefl,I sholl not empioy ony person in 9ny monner j ,j[7 � i; - � P�STRiCT GROUP 7YPE - • fIRE "�PROCESSED BY ADQRE55 � . t I_'! „ .. . N r-.!si -^, '<_J _ E-.,.i CQNST..'~p z ,.t�.-.. �:. � so os to become su6ject to the Workera'Compensation Eo,ws. � ��, �: � .. , . � . ��� _ Q � � . . � � � .� . . ' ClTY '� ✓r�: . ZIP 3 �!�� . � N . . . d. Dbte �� - AppiicaM �� ���-. -- t �- SiAT1574CAL CL4551FI TION � APf Cpypp. ' � ARCNITECT P, - _ TEL �` � NOTICE FO APPtICANL.lf,�ofter moking th�s Certificate of � �, ._ . •- • ,� � �/� � ��� d 6cemption, you should bacome subjec� to tbe Workers' EMG�NEER "" t NO c,>'a =�-` �:��ryp. � OwEtt.Uwis_ � � � . '� COmpen6atian proviSians Of tlle laI]or CacJe,YoO must{arth- ADDRESS�f' �I r.:" .��...5.� � .�`f... SEWe2 MAP . .. . � . �.. .H with�comply�with�.such provisions ar this permit shall 6e .,�,.,. ". " �' . ' � .. ._. � deemed revaked. � . � . CONTRAC70R x --�`7., ?L',7: �� _�r G . fe ` u�_TBK.... � p�. - - ��VALIDATtON� �; . .�- UCENSEDCONTRAC70RSDECLARATION��. " . - .. . . „� ; .ir r �:-.� •...:.>LIC: � . . .. . . . �. � �hereby affirm��ihot k amlicensed-under pcovisicns of:ChGplgr 9. ADDRESS � ryp, � � . � � �(commencengwithSection1000)a#Division3of.the9usinessand � � �., . -. ,YALURTIpN ... � . . �. Professions Code,ond��my-lieanse is in�f�tt fwce and.eKect. ...� C�Ty ..�' ,_ ''��-. `. :: -%-�`i . �LIC.� - -- , . . . . . . . ,... CLASS. ' S" . - . - -. � �� ": . . . .. .� ._._ . . ..,, -..� � � . SQ.F7 � �NO.OF .. . ... - . .licanse Number .. .� � Li0.Ciass � SRE � STORIES � M IlOiES �� CONE� . .. . . ��.�. . .: � . . . . � . � '7'�tr�:i �„ .,� .. NEW � : S ; ....' .. �. . . � � � 6ESCRI7TION-OF WpRK � ���p ' CoMractw � Dafe .. }� 4 ' . . Fti�-�- ` . . ' .�� �I om.exempt fwm fhe iiwnsing requirements as 1 am a i`+`-; _` �-�.."`�r.:�.%�:: ',,._,�' � . ADo Q .. ...� . . . �d.y a *'?^; r� .� licertsed archifect or a regntered pro#essianal eryineer� � � pLTER .� �" F{F{AL � � � ' � acting..`..in my professionaf capacity fSecHon 7051, � Q ��.�DA7E .. � .��� � . .' REPAIR � # ��;'�'� ' �� �-� Business undArofessions Code). �� . � . USE OF .; ,y-.�.- � � � � . �ANAI �� • �� - � � � - EXISIING BL�G ' �' �...- . .�MOL � � � � ;:� .Li[.orReg,Na. . � 6ale .... . . . APPLtfANT. , lEt'i� �BY � � .. . ��t`i�'`" _' . - -- � QWNER-BUtCDfR DECLARA110N � aR�MI FY� r-� No !'�-[_�• . - .: - � f hereby aff�rm that 1 am exempt from-the�Eontroeta's L�ceose �t� -� = � �� "� ' �- ` - -"�. . b.'�C..r�"��� � . . k;,. ,. .,.-, , , ..,. � �.law for ttJB following renson(Section 7D31_5, 8usiness ond AooRE55 �t•-=^-�"-�- 7� r't``(� - � . � .'.Professions:Gode)> � � . . ,..... .� � wte5ent . . . .. . . � � � . - �-." : ��� t, as owner of�ihe�ro e y p y ' �. BV�I�wG � � � � � . .. . . .. p p rty, a�m em lo ees-with ADORE55 . woges as7heit so�e tompensotion,will do ihe work ond � . � � � .. . � � . .�.`Fhe.struclure is no}�infended or otfered for wle(Sectian � �aA�ITV - . � � . . � . � � ' �� � �709a.Busn+e'ss ond Pfofess�ons Cods). . .�.: . � . MOViNG: � � � iet. - �� . � � � , � � � I,as owner of Ihe�propahy am exciusively conhaGting CONTRACTOR NO. �,�. ?`T.1, I -with Iicensed coniroUors fo constract the project(Sec- qODREss `�,.'l�an 7044.Bus�ikeu and Protessions Gode}. � . � � .. . . � ��.�i w�F'_"t . - CONSTRUCTION LENDING AGENCY �. -�REQUIREb ypRo Hwv TO7Al SE78AIX fROM Ex157. � � � �� �� r� � II �-SE7 BACK PROP.1lNE WIDTH . . � � � �,4 S� f j�,�.�-� ' `I bereby affirm tha�there is a construct�on lendinq ageocy for pRONi���� � � � � � � "the performonce of�the work for which this permit is issued . p.�. � � . � . - . h 4`��.� j .� .(Sec.3097 Civ...C:j. :. . � . . ��SiDE � . ri�. . e,it.,h' a„,.:.�.; - :�. . . � . � . _ P.L - � . � _- . , '.�.• I ,: � . . . � . � 7t:Y f �.:. .. � tender's Name . a ` � _7 �c� ��_� � ��'� �. � . .. . P.0 Fee$ ,� �.`" '` Permif Fee��� - � ` a =lender's.Address',� � ��� � I-ceAify ihaf I have read ihis qpplimtion ond stote�haf�he �� " � -�' Isw ce Fee � ; � � _ �j��•�e*'•�� .� obove informationfs correct..�bgree to comply with ollCounty � lnvesr�gotion Fee �� � � � ordinpqces an8'Slata taw3�relating�to boildi�g constr�ctiop, 7oialFee+ °�' � `��������' ornd heie6y aulborga represeniatives of this County to enter - . - _ .�� uporr;thp a6ove-men�qnRd Properry for inspedwn purposea � . �� � . � . . ... ���'' �'�`5�Y • s_� � y i �t i. �� � `��.; ""^�" �"J' `-' . � � SEE REVERiE FOR EXPIANATORY IANGUAGE � � � . -� � t ^ . � S�gncture a4 Appl mnf or Aqent . , Date _ '' . . .. . . . �i . . . . . � `. �s ' � i . � � � . . � � . -----�---1�--�_-,, i --;----i , . ,j � , I j ; � 'f ! � i� ± � f �.. ' t � � � �` t ' ;I . 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