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HomeMy WebLinkAbout1068A 1069A � � �� s � .. , _. __. WORKERS'COMPENSATlON DECLARA710N � � - - -- --- . :. �� -; � - - - - , y ,_ . . i ^ %� � '+ - � �. ,: _ , f hereby affvm thar I hhve a cernfcdte of consent�0 5a�f - qpp�ICATION FOR�-6�,l,I��.���� ��"�i��, "�' � ��sure,or a ce�ficate of Workers Compensahon Insurance, l `� ��� or a cerrit ed copy thereof(Sea 3800 Cab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Pol�cyNo�-'8648d9QompanyGmi:t AmeriCan � Certified copy is hereby fumished. - � -- FOR APPLfCANT TO FIlL1N- � - -� - -� au��o�Nc�������.. - � � � . _ .. . .. .. .... ADDRESS Certified copy is filed with the county building inspec- BU¢Dw _ r�o�department. q�oaessL0615 Cliinlxr DriVe oate�/9/88 ,appi�comR. ['haniar . arv ��laxid fi2lghts Z1P �p�A��7v �-�- - CERTIFICATE OF EXEMPTION PROM WORKERS' NO.OF 61DG5. ._ , NEAREST � COMPENSATION INSURANCE-- SIZE OF LOT � NOW ON LOT � �-�-'�--- � �� CRO55 ST.��- � � (This section need not be completed if}he permit�is for one � ASSESSOi(�� � � hundred dollars($100)or less.} TRpCT 33636 6LOIX LO7 NO. 29 MAP BOOiC ' PqGE PARCEL PRESI�Y OF SO CAL TE�660—Q660 use z e naaa I certify fhot in the performance-of fhe work for which ihis - OWNER - -NO. ,/� � � -.-- � pBFmit i5 issued,I shpll not employ any person in any manne� � qDDRES�7991 �7-tC�lell �011'�1 . !Q/Q�u CONDITIONS n'� � sa as to 6ecome su6ject ta the Workers'Compensation�aws. I��e. ,. . . 92�14� �9 6�,$ � o �, Date - -APPlicanf CITV _ ZIP 9A� . �T'— ,�; CryQHr r 1f .A NOTICE TO APPLICANT: If, ofter making�lhis Cerfificate of ENGHNEEi1��`�"eS Sandberg No547-3203�� o�sTe�cr GROUP TYPE FIRE SSED eY � O� Exemption, you -should�become subjea to the Workers' � ' .. COtv57. ZONE � �.� Com pensation provi4ions of the lpbar Code,you must forth- . q o o R E�1 0 E. 1 7�'1. S t.i �1 0 5� S�I 7.'�.��T�. �„ �� � � ��,�e W with comply with such proWsions or ihis permit shall be - � deemed revoked. . . . CONTRACTOR $3[112 �G pW11eY - NO. S7ATISTICAL CIASSIFICATION � �- ��-�-- Apf. CONDO. �� �}�� � LICENSED CONTRACTORS DECLARATION � ���,- . �.. . CLASS NO.S�DWELL,UNITSZL� —� I hereby affirm that I am Iicensed under provisions of Chap:er 9 ADDRESS Np, (mmmencingwith5ec1ion7060}ot�Division-3offheBusinessond SEWER-MAP �- --- -��- - _ _ LIC. Profess'rons Code,and my-license is in full force ond effect � CITY - - CLASS - - BK �: . VALIDATION . 527293 $�. s�'eF' 2316 5 ORI�ES 1 F MILOIES 1 CONE� �License Number Lia Class . � ���'� OF SO � � F1�9�EH DESCRIPTION OF WORK Sinqle Family NEW VALUATION GontraUor _ . . noo � � s E �.�;���'��.. . - ❑I am exemp�under Sea W1'�1 attaeIzed garage a c . ALTER � . . , � s� i 0.8P.C.for this.reasan Plan 143B REPAIR � s Daie: - USE OF �EMOL r R v J,Q y � . � EXISTING BIDG. ❑ Signafure - - APPLICANT - � .- - TEL. a .,^, I �i � OWNER-BUILDER DECLARATION PR�NT�R' C��1�'P.T n,o.660-0660 FINAL C} I hereby affirm thaP I am ezempt from the Cbniratlor's License DATE 9����� ���P _�:� Law for the following reason(Section 7031.5, Business and ADDRE55 17991�Mitehell South ITV711B FINAL � � C G-F;. Protessions Code): - � --- - p N � � By ��-� � ` � � � BUILDING . . . . " - ._ ' - -g � I, os owner of the properly, or my employees wifh ADDRESS � wdges as their sole tompensation,will do ihe work and ��A�TY , � �� ��i����,.,��� ihe struc�ure is not intended or offered for sale(Section - _ ' � 7044,Business and Professions Code). MOVING TEL y � 1,as owner of the property,om exclusively mntrocting CONTRACTOR NO. � ,_��,,,,�.ci � � with licensed conira�lors to consfruct ihe prpie[I(Sec- qDDRE55 ''-� (�`�' ' � tion 7044,Business�and Professions Code). �C;..;G-�R f3 � - REOIIIRED TOTAL SE78ACK F � CONSTRi1CTIONLENDING:4GENCV - - � SET-B.4CK Y/>RD HWY pROP.iItJE ��- �WIDTH I hereby affirm that there is p conslruction lending agenty for FRONT � the performance of the work for which fhis permii is issued P.L. (Sec 3097,Civ.C.). SIDE - N�A e.i. Lender's Nama 368.61 619.50 �or,w Ref.M c landei s Address � - R.C.-Fee$ Permir Fee _ _ -� - ' 3 / � $ I cerrify that I hove read ihis applimtion and state ihai�he � issuonce Fee 10•50 L�MA P/C N �� � obove info�mation is corcecf.I agree to tamply with all Coumy InvesYgar�on Fee � ordinances ond Stote laws-relating to 6mlding construction, Toml.Fee 630•�Q, IDMA perm.# �� : an ereby authori -representohves of this County ta enter "��"�-""-" m up he above-m tmned property for inspection p!rpos . � - - -- � � -� � � ---�- ------ -��� - � - -�- --- �- � -��- � � - � � � "�. 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