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HomeMy WebLinkAbout02_12_1987 - 21015 PATHFINDER RD WORKERS'COMPENSATION DECLARATION � � . � . �,� �� � � � � � �e.abY affirm �hal I hove a mrtificofe o,�o�Sa�,�o e�, �pp���AT10N FOR �3UILDING PERMIT inswe,or a cerlifica�e of Workers'Compensotion Insum ce, . . � or a cerfified copy�hereof(Sec:3800,Lob.C.) � � � ' �' � � COUNTY OF LOSANGELES BUILDING AND SAFETY PolicyNo�/'c.'7tLn�Lompany �/��_�'J^.�� . ❑ av v FOR APPLICANT TO FILL IN BUItDING ^� Certified w is hereb furnished. ADDRESS !i f / Q�� �( Cerlified topy is filed�wiih Iha counry ild' g ins o- � BUiIDiNG f - ��� fio�deparlmenL � AD�RESS �/Q�S � i„�. Date '��APPlica� CITV _ f� 21P . IOCALITY CERTIFiCATE OF EXEMPTiO tt0 ORKE S' � � r+o.oF eio�s. .... Nenaesi COMPENSATIO $U CE� . - $IZE Of LOT NOW ON LOT CROSS Si.- ' (This section need not be complet if tha permil is for one 7RAGT BLOLK LOT N0. �p�gpq( PAGE PARCEL hundred dollars(SI00)or less.) .. . "F�' USE ZONE �P 5'333 OWNER G/ G _ P 02 NO. I certify thm in tha performence of the work(or which this - /�1 ap permH is issuad,I shall not employ any parson in any mannar AODRE35 �L 19�f�U ,VGK'f �%I �ECIAL • � �� — so as to 6ecvme subject to the Workers'Compensation lvws. � CONDITIONS � Date " � APaheanr � . . .. an ' ll%�� Gb. Zta Z7/ ' - � -�d NOTICE TO APPLICANT: If, after makln �1hie Certtficate of AR�HITECTOR TE�• DISTRICT GROVP TYPE FIRE DBY O� g NGINEER NO. CpN$T.� ZONE H: Exemplion, you should betome sub�ect to.the Workers' � �� � U. Compansalion provieions of the Labor Code,yo�must forfh- pDDRESS � wllh tomply with-svth provislons or this pa�mlt shall be . �„�, yr p•o�� � TE�,,�,� S7AiI5TICALClAS51FlCATiDN APT. CONDO. Z� deemedrevoked. . � � � Cp T OR f NO.}S/�u'I IICENSED CONTRACTORS DECLARATION� .� . .i�C� �CtA55 NO. �� DWEII.UNRS - ^ . I hereby affirm fhat I am Itceneed under provblons of Chopror 9 n�DRE55 '/.SO Gcl. NO. O F ��R�P � (eommenefnq with Seetion 7000)of Dlvltion 9 of the Buslness and . ���, . . . Profe�eions Code,and my Ilcenaa ts in full fores ond effect �Itt AfL��/�� MSS � � BK;������-�� � VALIDATION� , a�7�0'. _ . /3/ ... . SQ•FT. NO.OF N0.OF CHECK . . Llceme Numbsr lic.Cloaa � SIZE STORIES FAMIlIES ONE y V'I� pESCRIvfIONOP WORK G/9�l� i � � '-VALUATION � ' Controctor// - •�LT� I �e 7%z—�7 N� ❑ / . . ADD � _ �.a a�a� , I om exemp�under Sec. �.S r ���.e AITER �j�j�.(7}{ . B.BP.C,for�his rwwn s s /' � _ � � - � - -� REPAIR #-• • . •2 yj us�oF � ��� � EXISTING BLDG. OEMOL ' • - Stgnaluro . . . . . APPLICANT TEL. FINAL �+ I •�•4 3.5 6 OW -BUI R D RATIO PRiNT NO. DATE ^�1��! . . e 2 t�3,�,{p� I hsreby affl af I om •mp om the Contmctor's llcense pODRe55 FINAL - low for fhe ollowinq rea (SeeHon 7031.5,Bvelneu and �� � � Pro�eislons Code): - sY � � � I, os owner of ihe propeity, or my employee�wi�h qoLDi55 z 3 5 1,7 A waqe�as ihelr sals compeneation,wlll do the wo�k and � � �. . . . �, 1 . the strvctvre Is nm Intended or offered for sole(Sectlon ����TY � • • � � 7044,Bvsinees and Professions Code). � - � . MOV�NG � � - � TE�• - I • r 6 1.7 5 � � I,os owner of the property,am extlueively coMracting . CONTRnQOR NO. � with litensed eontranon to tonsfroct the projeH(See- AODRE55 � � • '"'6 1,7 5 c=i tlon 7044,Buetnese ond Professlons Code). �',_` � - � CONSTRUGTION tEN�ING AGENCY � - �� �Qgq�g vaRD HWY� TOTAOR�LWE wiorA ' - �' . � .� � 0 2 1.3—8 7 � � I here6y otiirm that thera ie a construc�lon lending agency for ' FRONT the performance of iha work for which this pmmit is issoed P.l. � . - (Set.3097,Civ.C.). SIDE - P.L ..� '�-:,� � - . Lender's Nama � / �-^ �DMA Ref.M Lender's Address - � - �-- P.G Fee f •S(,, Permi�Fee �7�•ca� ' I certify thaf I have read this opplicalion and stote fhat 1he _. . lasuance Fee . Q J V IDMA P/C N � .. . above information is correcf.I agree to comply with all County � in�eergo�ion Fee ordinonces and S1ale aws relattng fo building construaion, Tolal Fee _ LpMA Perm,M - and here6y aulhoriz rep San1a1'es of fhis Counly lo enter �pon the obove• ti ed pr rty for Inspection purposas. � �� SEE REVERSF FOR E%PLANATORY LANGUAGE gno f App mnl or Ayenl . Do1e _ . . . _ . a ° _ - ' , T � i. T � � �. rG� -� c m . T�,. � , p � . .. f- CiD '� V- �� ' a' ;� Q m. Y,1' � A � 9 � � ,� � ] ('j ' .. p O p � J^ � ap. _p ry� = ,fl ', ` � ... d �O. 47 �'U �� � � �p r � � d. (`�� N p �„ ' S ' tP O t�9p � . , 'D� 7 ��� O -O 9 .� N '.^ . . . � . �' sy`^ o en T � ` P , c_,�J'a �r,,:'.�. " �, p'G o p - '� 7 1, . T r O 7 O 6 G-.a O�O 'O t . � 0 � � � f ' y � • � �Z'/' . 'Z p �? •�J O T".?. 'O a� - 7.. 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