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HomeMy WebLinkAbout1065A 1066A 1067A ,. .L e � � � _. _.�._._._,_ __... . ._ WORKERS COMPENSATION DECLARATION--' � -� -�� w "' T�' �� '`�' ��`^ ��- �' k . . . - ..� .. _ ..� __.� ..a x�. 6 .'&t � �.` j�r�� �.'= ■Ff `�. T`' i hereby affirm ihot I hove a certiflcate�of mnseN�lo 5e�f �� APPLICATION� FC�1R� BU���t���� �ir�I-\'� � � insure,or a certifimfe of-Workers'Cempensation Insuronce, or a certifed copy thereof(Sec.3800,Lob.C.) - . � - � � � - � - � - inTcP864809�0 Gxeat Ai�rican UILDING AND SAFETY COUNTY Of LOS ANGELES B ,_ P�olicyNo. . ampany ... .. ....._ ,.._. �.. . _.. _, . .:�._�,.. _ --_ „-s��-.,. :.,.� . -� Cer;i4led copy is hereby 4urnished. . ..-. FOR APPLICl�N7 TO FILL IN ADDRESS ` aCertified copy�s filed with the counry building inspeo g�i�pl - � tion depor�finen�. - . ADDRE"s�0620 Climt�r Drive , oa�e 6�9I88 Appliwn�R• ��i� arr R[�wlaxid Hei hts ziP �oc,u�rv CERTIFICATE OF EXEMPTfON FROM WORKERS'- -�, . . .... . NO.OF BLDGS... . . NEAREST � COMPENSATIONINSURANCE . � � - SIZE oF LOT _ NOW ON LOT � .. CR655 SL . (This eection need not be<ompleted if the parmir is for one ..33(36 ],$ ASSES50R- � . bundred doflars(E100)or-Iess.J TRACT BLOCK LOT NO. � Mqp gOOK . . PAGE PARCEL OWNERP�SLEY OF SO CP,T rypvF)O-OSF>O USEZONE- �v �� � � p I�ertify thet�in ihe performance of ihe work for which this - � -� - . ,\ � NO, -Z-d permir is-issued,I shall nof employ any person in any monner � � 0 G SPECIAL �� so as lo become subjecl fo 1he Workers'Compensatioh Laws. P.DORESS1,7941. M1'C.CY121I. SOUtYl . �l CONDIiIONS Lf.$ arv Ixvine Z1P 92714 �?. Date - Applicant � - -- �ISTRICT GROUP ttPE �IRE P SED BY O�- ARGKIT��qg�,, TEL . �NOTICE TO APPIfCANT: If, ofter making�rhis Cerhficote of ENGINEEk�`��1G'S Sandberg No, 547-3203 �p�T ZONE V Ezamption you should becoma subject to the Workers'� - - - Campensahon pravisions of 1he.Labar Code,you must farth- ADDRES�LO E. 17�1 S�. #105 �Santa Ana �.. �.,� � �� with comply with such.provisions or }his permit shall be � � � TEL. � - � STqTISTICAI CL4551FlCATION ' - A7T. CONDO. �� deemed ravoked. . - S�TT12 d5 S�NY1PS � CONTRACTOR NO. IICENSEDCONTRACTORSDECLARATION- � � .. ���. QASS�NO.�DWELL.UNiiS� �_ I hereby affirm ihat I am licensed under provisians of Chaple?9 ADDRESS NO. (commencing with Secfion 700DJ�of Dwision 3 of the B�Siness and ��� - � SEWER MAP Professions Code,and my license is-in full force ond effeci. - Ci7v - Z?CtiZ CLA55 gK- � - YALIDATION 527293 Bl SOE� � sToa�s 2 PMi�Es 1 oNeK �6�•:�, License Number Lic.Class -� � � � L � u PRL'JI+EY OF SO C,� 6�9�HS DESCRIPTION OF WORK S1Ilgle F31TII,1]7 W1tI1 NEW � VALUATION � �a � g 3 G z Gontracfor ... afe ADD � ; ��1 , �I om exempt under Sec. . attdCYl� �d qL7ER � � $ ` y�~�� �4�C �. t t �':S3?,'.� 8,8P.C.forlhis reason Plan�� REPAIR -� DoTe: USEAF . . . DEMOL ❑ �i � -� r�A EXISTING 6LDG. ;,'v G-�..,.,. = - � � � $ignature - - APPLICANt R. -Chenier � � TE`.660-0660- FiNA� OWNER-BUILDERDECLARATION � � -� - PRM71 NO. ._. pATE �t'��� �- i '�.,p.�!'i .. I hereby affirm that I am exempt from ihe Contractar's License qD�RESS 17991 Mitchell South p�Np� � �-_.e�v�r::i j Law for ihe following reason(Section 7031.5, 6usiness and �- �-��- �f1� � -�_ - � - Professions Code)� PR EN� . � � BV F ����� BUILDING � I, as owner of ihe properiy, or my employees wi�h ADDRE55 � / �!`y •^, wages as their sole compensalion,will do Ihe work and LOCALITY , the sYructure is nat in�ended or offered for sale(Section . � � 7044,Bosiness and Profess+ons Code1. MOVING TE� ��'-`y�'���` � - � I,os owner of fhe property,am exclusively coniracting GOM7RACTOR .NO. with licensed canirodors to construct the projeu(Ser � - ti��.U�C`�-t-` tion 70d4,Business and Professions Code). ADDRE55 . . .._,. _. „- . CONSTRUCTION-CENDING AGENCY SET�BACK YARD HWY � TOiAPS�ETeACrKEFR � � WIDT}1�� _=� �-'a�I A - � I hereby affirm fha�ihere is a construdion lending agency for FRONT � ,y s �-e m '{�- � rhe performanw oF 1he work for wh�ich this permit is issued G-t. (Sec.3b97,Civ.C.). � . S�oE � � i s y-J 3,-v{j-�� - P.L. Lender's Name AS/A � IDMA Ref.8 ->'� �'`l- 'a P.C.Fee-$ � _ . .Perm't Fea ����� � . ; lander's Address � �.,f,.�> � fO'� G 1 �f�j- �. � I cenify rhat I have read fhis applicalion ond sYafe that ihe �'"��`v� Issoonce fee ,_.. _.,.: LDMA P/C N � , > obove information is cwrect.I agree to comply with oll Coonty '�� i��e ,anon Fe c ;� ordinances and Stote lows relofing to building construction, . - ��. �a,�, ��j���— Tmal Fee �T ���' LDMA Perm,# �v7 f ; an hereby auth rize represento�ides of this County-fo enrei . s o the obov entioned property for inspeaion urposes. �� � � � - � - � E . ///''''��) ` �J . . . . .. . .. ____....._.._. . , ., . .�� y� ry� SfE IIEYHlSE FOR EXMANATOR`I IANWAGE�� � � Signature of Appli� or Agenr Dare . . . . . . . . . ��,�_._ ._�. ; � , , , . �"", --'m C�: �t.,t-B� t rk a�?r � ,r� _.�_ ��7 a '� � ! ;rz F ���:;n..��Es --. ; t�...,._ . �_. . ._. ..�-. . . ; �.._» ._ . .�:_ ,� w� M,�.�...«=_.a..... - �-,. - �' c'"- 0 . .'� F - -- � I _ _ _-. e �vh ��e 7� [ '-a -� ge#u;nQr� .i� . . _ . . . - . . �. �_._ . � � �f'➢,%1`i+d i _ ,_ ..�..___._ _,—..�-.. � , � F.� ) S C � C P '9 P �.' 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