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HomeMy WebLinkAbout05_08_1985 - 21073 PATHFINDER RD . . . . .: . : _... _ _ .,_..-- -._.__ _ _ _._.._ - --.._ ._.._ _.__..- -- . .. _,�.... . . . WORKER$'COMPENSATION DECIARATION I �� -= - � ���"' �� .� I '�� ' � � - '� . ..., ... . .. . . .. . . APPLICATION FOR� �UILDING PERMIT �! I hereby aff rm that I have a ce�tif¢ata of�consent to self � insure,or a terfifimie of Worken'Compensation Insuronca, � � . . _._ . . - -- - - - . .. . . �. - ` ---.'. or �'tertified topylNeieof(Sec.3800t'}La6.C.)� � ' I� - �� - � COUNTY OF LOS ANGELES ' BUILDING AND SAfETY - PoTityNo. �+� '�Company 1�ilG.ttlLk�unC INC . 1 6UIlDING ' � � Gertified copy is hereby furnished _� FOR APPLICANT TO FILL IN qDose � _' �,y Certified copy is(led'wilh the-to y aJding�inipec- �'-�-� gUILDING i � — / �7 � I �� fion department. � � ' � � �� � ADDRE55 U�� �i � 1 � � ' ,,� v/�.. � , _ �. , ..... . ___ _ . . ._ . _ . . -� � Date..�..`�/�)- ...Applimnl � . , . CIN�QSAd� ��(1. ZIP IOCALIN � � ' . .'CERTIFICATE OP EXEMP FROM WORKERS' .-. - .. ...- ..---- �- �:oF Btocs.-_ . -..-�-. n�a.aEsi.... ._ ._. .. .:_.. . .... .. .__ .._.._.�.. ._ � � �• � � �COMPENSATI 1 URANCE'� �' � � ' S¢e OF toi NOW ON lOT ! CROSS ST. ,. (This�seclion need not be'co pl ed if the'permil ii for one n5SE5SOR � �'-'--- �� - " ��- ; ;.__ ._ _.... .... ._._' _- . _ '.'_._._._.: . ,. � hundred dollars($100)or 1e53. -� ., , ,, . TRACT� BLOCK l0T�O. - (�Mp gpOK` ' ` PAGE�I PARCEI .,. �, � . .. . .. - . . .,� . ._'.'. OWNER �4"1N -. ___ • f!{1 � USEZONE � . . . .. �. =3 > I certify that in Iha,performdnte o�Ihe work for which this - � . ,a .. (�^ {� ` �. I--�--�--' SPECIAL. .___ ... .---•- .._.._ . ._ ._. permit is issoed,I sFoll not employ ony person in ony monner ADDRESS��� L� 1�/�'� - `=-�- V�1+----� �-�- CONDITIONS ��0 so es to become iubject ro the Workers'Compensd�ion laws. �.{„) ,,. ., „ , : � _ . 0`�-63'4'0�.� _ _. . _ _.. Date �-. '�.�. ��. ...�Applicanf. :. ' .,. . _.�; . � . Cirv..,�lJl N�..... ._ . ZIP._. Z _ . . . _ r � . . , ... , �O NOTICE TO APPLICANT: If oflei moWng Ihis Cerfificafa of ARCHITECTOR N ^-�� NE IDISTRICT__.GROUP. TYPE 'FIRE _ PR SSED BY �F __ ENGWEER � 'W Exemption,'yov-should become��subjed ro��the Workers -'� CONS�r ZONE . �V Compensoiion provisiens ef the Laber Code,�you�murt forth- ADCQESS�t1� Ss „ 4.¢h11+� v�� ���--- - C+'-� !� � wilh comply witFi.svch�provisions or thirpe�mit shall be -��-�- ,...� n� ipN � ! APT. CONDO.� - �,Z deemed revoked.�.�,.�.� �.����. .. '.�. .:.. � ...�..:�, "t,�(�,' � STATISTICALCLASSIFICAT ._ COMRACTOR �� �-�.-d�X tJ0 � . I . . '>>r�.. .---� - --.- . --- --.._---- IICENSED CONTRACTORS DECLARATION �. ��� ---- -� - �-!-��e� - �./� -� -- LIC.�--�-��� � '� MSS NO.�SLDWELL.UNIiS ' � . I hereby afiirm thal l am licensed�nder provisions of Chapter9 ADDRE55!-7b � N!� �,4` NO. � ��R�P � ([ommencing with Sedion 7000)of�ivision 3 of the Business and _�.. _ . . .. -_ _. . . '__ _. - LIC. .�J. .. ; � i Professions Code,ond my litense is in full force and eifetl. CI7Y �1/U�N� CIASS `"� -i"-"-�BK���7 � 1 - - VAIIOATION� � - �. �.. . �. [� � - .�, . � ��� _...__. Sp.FT. NO.OF Np.OF CHECK ' .. Ucensa Number ��1 l��r �� " Lrc Cldss ' � SIZE .. . ..-. � STORIES � ---�� FAM�LIES .. _. .- ONE � ., . . ,� ? . . _ . . �, � _�VALUATION_ . . _ I�- - . . Q���� (, OESCRIPTION OP WORK _ �.____ ___. . _ _ NEW- ❑ I CoMrador�n`x(�� "°��"� Dare .-�� ...� ..� ��� � � � ' � :s ���,� 4653A .. . .. ��LFYi .._�NG- �V� ADD - . �I am exempt under Sec '..."" .�.._- ALTER � . , � -�-� � ' .. � .., -.. . .. . . �� . . �.� ._. , i - . . B.BP.C.for thi reason _._ REPAIR_❑ ..�s. " . .- .. .... . '. . . - �• • • w'�-3__,. � .-..' . . USE OF � ':' � � � �_. .._. _ _.__. . _ ._ . ._._ • ate: E%IS71NG BLDG. DEMOL ❑ _ ._. �.•_•.2.F��.___' -- ;.,. . _ .._ � -' $igrialvre,_., __._ .. --� nFeu�GiNTT T1 NO. i FINAL l� ' . • � •G rJ O O c=i � O R-BUIIDER DECLARATION ! _ __ _ _. 1 '. _ __ _ �-�DATE��-=� � - -- - -� -�- � -1 hereby affirm t at 1 m exempt from ihe Controtlor's litanse � qpDRE55 ��I L M+ /1�✓N� j FINAL ' - - �_ O S O-R-S 5 ' Law for the foll wf 'reason(Section 7031.5,Bus(ness and � � . : � - --- - .._ . _.. "Professions Cod : _ _ _. . ... . _ PeeseNT i ey- / �4 6 S.'4 A. BUILDING � . � ' � I, as owner of fhe properly, or my emplayees with �, nDDRE55 ,f.. .. _�._�. ._ ...___. � ' woges as thei�sole compensation,will do the work and ���m, ; • ; � � • • T tha structura is not imended or offered for sole(Section � � ' _ " � -7044.-BusinessandProfessionsCode). "'- -���.-' ... ' MOVING"'- . ... ... - .. . _...TEt... . . .. ' -�- ---' � . �- -- " ��--^�D CONTRACfOR NO. I � I,az owner of the prvperty,�om exdusively tonMacting __.� _ � � a � witklicensed tontradors to�construct 1he project(Sec- -- ....- '--` ----` - "' "" '�-'-- �--- ." .. . . --'--�- -�.. . -_.._ _. ...__ ; r J C x fion 7044,B�siness and Pro(essions Coda�. ADDRESS , ' • �3 ._..._. ._._., ..CONSTRUCTfON LENUING-AGENCY_..----- -�.. SEBACK- YARD� HWY �TOIAIv OTP L NEFROm wIDiH i - _��� .._� -�- --'.� .._�. .. -_ .�... :.O�G��-E 5.. .�." ' I hereby af(i�m thal there is a consnutlion lending agency for � ppONi � " � � ' the performenca ot the workfor whichthis permit ie issved .. -. -.v.L-- .. . .-.-- -- . . .- --- -.._ . ..-. - ...-.... : � -------- ------. . _.. __.�._ . ..-_:_--- (Sec.3097.Civ.C.). . � SiDE . - _���. � � . . .. .__.._.._.._. . .. .__..____._. _.... ._._. P.t. _ _ ._ � . ._. - ._ " .._._ ._ . ___ ... ._. . _ . _ ._ _.__.. ._. .. .__,... ... �-; Lenders Name � - - � . , , IOMA Ref.N . _ ._. .- _'____... .____... . . .. _ . . ._ . . . P.C.Fee S Permit Fee ._ .. _ .� ._ -'. . lender's Address � � �� �1 .J cetlify at I have ea this applitation and stafe that.ihe ._..__ .._ ..__. . __ .__- _ Issuonce Fee- �- IDMA P/C N---. -._.. -.--� ,-' -' __. _ ..�.._. •� , above in rmotlon i corte t.I agrea to tomply with all County invesiigotion Fee ; I � ordinanc and 1 e law .reloting to building consirotfion. _._... .._ . _'_ _______. ..__..__ _ Tarol Fee... . .-' --' -iDMA Perm:M- --'----'---. _......- -' .".__ .,,...��..� ���-� �. and here y aot ri a re esentatives of this Counry to enfer � opon the bove fio e property for inspecti n orposes. � _ __ _ __ � _. ..._... . . . ._ . ... - -. .. . r -- -/ ... .. __ _ ._ .. . _.. . .. . _._... -'--- . ._ _._.._ ._ . � � / ' : SEE REVERSE FOR E%PUNATORY LANGUAGE � ' i .._ ._.Sgn reofApplimntorAgenr .- ._.. _ Date__ ._ .. ... . _ .__".- .__. .. _ ._._ ._.�..�.. .. ._._. _"_ ' ._._. .___ . 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