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HomeMy WebLinkAbout1446A 1651A (8) , -. , � '' , � WORKERS'COMPENSATIONDECIARATION "I---._.._..___..'--'_.. - - -- - . ..'.-_"" '-"'_._' '- -'-'--...-. ._ ..---' .. .. . : . ..,_.__..._ -___.:. _ -_.- "' ".-'_"..... �' _ _. . . .. ..�.. . ..,�:: .,,i-'., . : , . -. .., . _, . . .. ,.. -, _. ..._..-'-"'.-'-'..-.._ '� ..:.,: � .. .. _ ... � ,. ' . __.. .-- _ ". .. . -�1 hereby ot,;,m that I have a certificate of.consent.to.self APPLICATION FOR.�BUILDING�PERMIT�-� �: insure,or a certificate of Workeri Compensotion Insuranta, � Cerrified py is hereby furnished.f I��� �NS FOR APPLOICANT OFFILOLSN N ... _ .__. .. or o cerr�fled co thereo Sec,3800,tab.C.) ' GELES ' ' BUILDING AND SAFETY.. � - Polfcy No0�-y�3CompanyN+i' - � -� -'---- -- - - -� - '� C7 BUILDING J �.J'` ADDZESS `�-� /�A"Ti�IF/•c.JD�".e �.' � �Certified copy�s fJ,ed wiih Ihe coumy butlding Inipeo- � ' BuuDiNG /J�f-rr� � '�tion depa�tment.; , � � ` , � ADDRE55 /�j�+/TF/���'e� � ��d�� ' . .. oo�eFbs 85 . nPai��a�� - cm�i.4rxcx�0 /fi2.� z�P iouurr 17/�4�o.Jo �3,¢�� . .,. . . , ' ��' CERTIFICAiE OF EXEMPTION FROM WORKERS'��'" ��`�� � -- - --��� - ��'- -� � �" 'NO:OF BLOGS. --�--�-�----7. NEAfEST�- � �' ' "�COMPENSATION INSURANCE' � ' ' SIZE OF LO7 NOwON LOT E CRO:S ST.,,�F.,J� C����'J �• .. :.; � � P P � for'one •� J "� AAESSOR... . ��---- - � ., ., .. .,:.� . . " _ _'__�__ ..... _ . .. _ : This secfiou need not be com lefed if Ihe ermil is TRACT�4S Z BLOCK '-� LOT NO. � �y�qp gppg� � � � PAGE PARCEL _hundred dollars(EI00)or�ess.) . , � �, . . � �� ' _ TEI.'� / /, I,certify that in Ihe performance�of the work�for which ihis - OWNER� /ti�E�.�""--NO. ��Z N OP '/O`✓' 3 � � � - �r permit is is:ued,I shall not employ any person in any manner ���� - SPEC�nL�� �7 - - � � ,O.• L _._ _ ADDRE55" �L-I�H/]T�EZL�--- /TF�V� CpNDIT10N5 G U ��l� NOTICE TO APPLICAN7:��If,�aRermakln Ihis Cerliiical W5 ' _ saastobecomesu 'ecttPoPfheWorkers'9omensa�ionL GITY� /NE-. -._ __-__.__.-LP_.9 7/ .-.�' '1,.- -�----. - '. .---'--'--'- -. ..--'-.�..--- -� U � P. „ Oate " � A �icam ' " "' -'--' ' ' . � .. �� e of ARCHITECT OR TEI. ' DISTRIQ_. GROUP. TYPE..:_.. ._. .FIRE.... _ VROCESSE�BY. - � Exemption,'you�shoald become iu6ject�to�the'Workers' -�--�� FNGiNEER .v �V�-�-E'V N0.�3 - 1 �ONST.��/ ZONE I Compensation provisions of�he Labor Code,you must forfh- qpORE55 'Q � � UrnA � 9Z�P(f�� - �''p�- �� -- f[/� L-��- ��� 1 W with�mmp�y with�such provisions or lhis permit sholl be---��- � � , H deemed revoked. . •,. . - � TE�� q S7ATISTICAL QASSIFI ATION � APf. CONOO. �, . , .; -.... •. . ...�.,. CONTRACfOR � CO/75�T NO.��O-!� .'_' "� _' Z LICENSEDCONTRACTORSDECLARATION �.•.'.�r ---- - -----. .. .- -�---...... .I- ..-...----��C.- -�--� '---; ClAS5N0. DWELL UNITS. , ..- --- I hereby offirm ihat 1 am litensed under provisions of Chap�er 9 ADDRE55 �p i T�ne NO.3�7s3 � (tommenting wi�h Section 7000)oi Division 3 of�he Business and ..�, _.._ ._� . .... ��R�`P � ' ' -' ' --'. ...._..... .-'--' -• Professioni Code;ond rtiy license is in full force and eHecL �Itt .,L f'V��1C ^J ')/� CtA55 �`� --'�"'"'--'---�---�� �- �' ---'- - " ' " Li . . . . .. �. ,,, . .. . ' ' �,, 54.F7. NO.OF .. .. NO.OF._._...._..._._. BK. PG. . . . , 5.�. . ,. , �,�/,'� _-,.. _ . CHECK_i . . � . • , -. Lia Closs�� SIZE O S70RIES � FAMIUES ONE . ',� , , censeNumbe�, ��3 ' ._YAIUATION.. � �l __.. � . ., - ,.,��� " . ___... DESCRIPf10N OF WORK__ ' _ .. O -� .,._._.____._. Conira[for-/HTl�/r nif •�.:'_. / ___ NEyy'_' [�. .._ ....- � .. t� s, oa,a ir6 S'sS s ,SGp��.�, . �I am exempt under Sec: � � ADD Q ,_1� ..._._.. ._ --- . . -3.-�[// if.-..-_........--'- -...._...,.0 �-- �-- -� --- . . - •. ,: �. . . AUER . , • B.&P.C.for rhis reason -j-- - • t�A'�-L' REPAIR-Q S -- . - -. ' - ---�� [l r,�.0, .. .__ _'. .._.._ __.... _.. . . _.._. ..._ � USEOF � . . . __'__DafeF � DEMOL Q .._.._._. . __ Ii�'•_•_•l'J_, . . � EXISTING BLDG. � � ""- APRICANT - . � ` TEL. 'y • FINAI / ...-_" ..._ .._._. ._..... ..... c • � Sigri6fure �. ? � � 2 5,�� ,. '� OWNER•BUILDER DECLARATION vRiM t.rt� �G e �P --DATE. -5�^��- -������ � � � -�---�-�-� - � � -•I hereby oifirm that I am exempt from tha Contrattor's license pODRES$ 74NZ Nl Tch II l' �/��y1 e ' �'�� -+ � • •'`!5',�:•�_ � Law for fhe following'reason(Sedion 7031.5,Business and � � � FINAL� ' ��`�' �'"� '� -•-'_'_--.'-__ . _. . :..._ . � _ . "Pro(essions Cbde):�-� '""-'� �� � "" pRE N7 � 0Y � � � �G�.�2 S'--�S . .❑ BUILDING _... _ ..._ '___ ._.. . .. '__ ___ .. _ _ _ . _ ' I, os owner of the.properfy,.or my emplayees with ADDRE55 wages as their sole tompensation,will do the work ond i�i ry . . � : � � Ihe structura is not intended or offered for sole(Section � � � � � ' '" � � ..._.. 704a,Bosiness ond Professions CodaJ.-' - - - - nnoviNG ---.. -.._._ ._�-------_----�i.--- ._ ... ,, ...-- - --. -_---_.. ---- -- -._ .__... ._. .._. � I,as owner of the ro ert am extlusivel conlractin CONTRACTOR NO. ' � - !- r P P Y. Y 9 I r�.1 L7,x� 1� `� with licensed mntraclors to conslrucf ihe project[Sec-'--"- ADDRESS ..." �' ���� ��`�_� �_�����'�-�-- � -�' ��-....-'� � . - �.�....-��--�-� � --��-� ... ;�a •v • � . lion 7044,0usiness and Professions Code). , � . � : � � � :� " ''-'_'_"" '-'__ .REQUIRED -YARO' 'HWY. . iOTAL SETBACK FR . . I ' ^ ^ ' "'_' ._. _._ ..__' '." ' _"___.._'__'� . •�.�LA-�.�-. CONSTRUCTION tENDING-AGENCY-�--� - sei anCK PROP.LWE WIDTH � I hereby ofiirm that there fs a construUion lending agency for , iRONi ' � ' � � ` � i - �he performance of tha work lor which this permit is issaed -.! ..-a.t�---- --.. .--"- - - ...---------- ----' - -�---�'----'-._ . . .:. .._.. _.. ti... a:o.?��-']�?.: (Sea 3097,Civ.C.�. . '� SiDE � ' -" � ._. .. ._ _ ._. . . ..... ..__ _.____'_ _'_"_ _.,. P.l. ...... ,'_. _ __'_ __.__._. . ... . . . 1'______.'_._. . __ '. .'_'._ � .�2.v�-'�..ri_ .. i lender's Name � ._ .'-- ' -'. ' 0 -Z J[' lDN1A Re(.8 � � . . • •:� . .___ ' __ '__ '_'" ...' ' _.. ... P.C:Fee S--__-�'�_,�._' Permi�Fea__' �'L . _ _"_ __'_' ' _ Lender's Address ' � �.� . .-I certif thm I hove read�his d liwtion-and stata that the , �'�"�. � '. Y PP _.._ . , "." _ ."."_..... __. Issuance Fee- _IOr S� _. LDM1 P/C M "_.' .._ ,-'._'�_.'. __ .... _ ,.___t above information Is correct.I ogree to comply wiih all County ! Inves�igatian Fee � � ordinances and Srate laws relating to build�n9 construction, ._ ,'}�p 7,J, " " ' ��' :� . .."._.' .'..'._... ._.._. Tarol Fee._'._' .' . ... . LDM1M Perm.M_._. ..._ _ '__'_' ...._ ' . _ _.. __ _ � _. .._. . ond hereby autho�ize representolives of ihis County to enter upon tha ybove•menY ned property for inspection purposes. � ' -- • - ---. . . . _ ...-_" ' .•-- - ' ."'. '--"-'-__.___. _.. . ... . --. . '.-- - ----'_' .- -- � - -"_ - .-' . /�����j���e� 2 � SEE REVERSE FOR fxPLANATORV LANGUIIGE I � ' : i 7 i SignaNre of Appli<an r AgeM.._ " ' oie' '" ' . _. . . ._""_ _ .. . . . �.' _"' 1 _'_ ' .._ .. " _"I .... 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