HomeMy WebLinkAbout05_01_1989 - 505 NAVAJO SPRINGS RD WORKEF'. ,r,OMPENSATION DEQARATION . � �
I hereby affirm�' i�ha�a a cenificate of�o�,e�<<o self p �AT I O N F O R B U I L D 1 N G P E RM I T � �
insure,or a cer� ��e of Workers'CompensaHon Insuronce, � _ . . ,.. . . .. ,.
or a certified,c ✓ihereof(Sec.3800,tob.C.) N UNTY`OF LOS ANGELES.. . ._ _ , _.BUILpING AND SAFETY
���, Company ��U/�/C-�I{`,T Y � . . . ... ..
❑ �_. . . . ._ .. BUItDING � �
^/cenified copy is hereby fumished. j/�' APP6ICANT TQFILL'IN ADDRE55 �� ��Q
YG Certifled copy is filed with the mvnty boilding tn���{ � � . �u��"' ��p��i '.--- - - - � � � � � -
� Ilon departmeM.- � � , � f { ,1� �1 h�� � �i /�
Dafa`� ` `�� APPI(cant'-'�'��//��� � CIN I� !l /v�F/'.,. . ICe• ZIP� 7I�COJ IODUTY �`a,�(^(\ .. . .
NO.OF 6LW5. NEAREST �
-� CERTIFICATE OF EXEMPTION FROM WORKERS' � � SIZE OF LOT- � � - - NOW ON LOT ��-� � CROSS ST.
COMPENSATION INSURANCE � quEupg �
Qhiz section need not be completed if the permit is for one � TRAR � - � � � BIOCK --� � loT ta0.- Mqp BOOK - PAGE PARCEL��-� �
hvndred dollars(5100)or less.) � � � " ��/ n TEL '
. � . � OWNER/(i// ,O /y .N USE 20NE MAP . . . .
' -'� �� ' �' �- . . NO. �
1 tertify that�in the performance of the work for whith ihis �f SPECIAL. . � � � - - � � a
permit is issued,I shall nol employ any person in any monner - ADDRES !/ � - CONDITIONS �
so as to become sub�ect to the Workers'Compensation Laws. , O
an /gf�W/.�.. �/�P_ / ,
Date AppliCanf - - ARCHITECT OR TEL. �-- DISTRICI GROUP TYPE fIRE PROCESSED 8Y �
NOTICE TO APPIICANT: If, ofter makfng ihis Ce�lificota of . ENGINEER _ NO. � � CONS�T. r� Z� �(� �
Ezemption, yov should become subject to ihe Workers' `,� `' ��
Compensation provisions of iha Lobor Code,�yoo must forth- . ADDRE55 Q��� `\ -i ���•�� a
.wi�h fom()�y With�SUGh PfOvi5iOn5 of ihi5 permit shall be /0 /L,n ��.s afl�/1(��. STATISTICAL C1A551FICATION � APT. CONDO. Z
.deemed revoked. . - GONTRACiOR ! �(K[�� i��� TU ; _ _.
UCENSED CONTRACTORS DECLARATION � uC.� �/ QASS NO.�DwELL.UNiTS �. � . .
I hereby affirm�hot I am licensed vnder provisions of Chopter 9 _ ADDRESS '�� �• � sEwER MAP �
(commendng with Sec�ion 7000)of Division 3 of fhe Bosiness /� �06,� ❑C. � �
and Professions Coda,and my licensa is in full force and effeU. - dN�../"'1 � CV+SS � BK � VALIDATION ..
��948� c 3s �°.E` � STORI�ES �ILOIES / ONE
License Number Lic.Class � - �
rfIA ,• f c�� VAlUAT10N
CoMractor�ry/���UN�DaIe� � DESCRIFfION OF WORK R�%/OU.L� 19�� � ❑ S D .
�'j f lG 1�GhT T A�i29C�,c �""�' D '
❑I am exempt vnder Sec. � � � �
. . AITFR ❑ . . .. . . _.. ._ _ �...
. � 8.8P.C.for this reoson. . . .�'�8.� �.c���9... . � �-... .aEPaiR❑ s . . � � -
USE OF " "__ __... ... _. _ . . . .. .
Dafe: � � - � - . . __ ._._._. DFMOL❑ j
. .. . IXISi1NG BIDG, � .
. :Si nature - � AVPLIUNT G TEI. FINAL /�. . . '. ... .. ,
9 OWNER•BUILDER DECLAR.4TION . . �f��NT1 ��--/���//� n�a824 3g2 DATE 5�
I hereby affirm that I om exempt from ihe Controttor's Litenee � � A�DRFSS �� ��- � ��- - - - '
Law for the following reasan(Section 7031.5,Business and ��� FINAL�; : -- . . �
.Wofessions Code):. . . . . . vaeSeNi . . . . _. ._. . . -,BY�-- - - .
� � BUILOING
❑ I,as owner of the properfy, or my employees with ADDRESS " •
wagee as their sole compensation;will do the work and � � � - � - --� � ��- --� � - - �-� - � - .
the sfrudure Is not intended or offered for wle(Section � ��'��N � , - �
-- 7044�Business and Rofessions Code:) . . . � MOVING .:. .. .. ....TEL. . ._. . - - - . .
❑ I,as owner of the proper}y,am exclusively coMrading CONTRACTOR NO. , �b CI a�0 p
�� � wifh licensed contradors to consirutf the projed(Seo- .. ADORE55... . . .... ...... .. ....`..- . .. .. . . . " . � � - - �- f�d� • 1 - �
tion 7044,Bosiness and Professions Code.) - � �
� CONSTRUCTION LENOING AGENCY � � �SEQBAGC YARD -HWY� '�T�iApROPiiniEfeOM � .�ioTH .. - � � � -2 a-s�Q S O �
I hereby offirm thot ihere is a co�strudion lending agency for FRON7 � - �� '
" the perPormanca of ihe work for wh�ch this permit is Issued P.L �- � � � � � - � •o •�`���,_ �
�
(Sec.3b97.Civ.C.). . . . . SIDE � �.
. . _ . . . . ' _ ' . P.L.. . � . ..___ .. . . .. - - D.�,.O� -O�
Lenders Name . � O •^,A LpMA Rei.X _ �
' - ��� ' - P.C.Fea S - Pe�mi(Fee L3.7 � � �
Lender's Address �
�1 cerfify that I have reod this opplicotion and state that tha ��� �- ����� - �� ��� Issuonce Fee --1�. IOMA P/C M � "-- _ - � �. ��
obove informotio torrett.�ogree to comply wifh all County in�es+�gaeon Fee- �
_ . . . .. . � . . . ' _... ._ . _ _. .. .'•.�,
ordinonces an ate laws rebting to building constroction, -� iorai Fea LDMA Perm.8- - ; � .
and hereb i ese lives of this CovNy fo enler � � ' ..
" upo �ion d rly for inspeclion p�rp es. ' �. ��� � -� "�� -" , � � � , � - -
�SFE REVERSE FOR EXPIANATORY IANGUAGE
. _ . ...._.. .. . . . . _._.. . _ .. _ . .. _ .
Si iure of Apptimm or Agent afe � .. . . ..
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