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HomeMy WebLinkAbout1113A 1114A (5) ti , , . .._ -----______..._. ._._..___..._.._......_.__. ___....___._—._---- - •----..__._ ._..... :_,_. :. ..._.�..------__ . ' ,�WORKERS'COMPENSATION DECLARATION , � "'����"���"����-"�"' ' ��`" -� � �� '' _. � ... . . . . .__.___._.�....._... .._ _ � � � �- , .. , - - --' -- --�-'-- - - -- - -_ i hereby a(tVm that 1 hava a cerlificate.of consent�o.self APPLICATIQN FOR BUILDING PERMIT .insJ�e,o�a certifim�e of Workers'Compensarion Insuronce, _ • �. ,.., . ...._ ----.... . - � - - - � ---- � or a cerrifed copy the�eof(Sec.3900,Lab.C) COUNTY OF LOS ANGELES BUILDING AND SAFETY - 73Y�QQ5-27�4-0004 Natioravide� 10/C .... _ .. _ . '- -- - . �: P�olicy No. � ompony - .., . . BUItO�NG ' Cer�iiied copy is hereby furnished: ✓ FOR APPLICANT TO FILL IN qppRE55 679 N. Feathen�ocl Drive � Certified copy ts filed wirh'ihe counry building insper - � �-- 8Uii0WG 679 N. Featheswoocl Drive , � +, tion deparfinenl: � ' ' ` ADDRE55 Do�e. F)��.9�HG A'PP�iconi,..�`� ANDEDT GImUP --�--- cm Diannrri BaY 21P 91765 , �ocnur Diatmlxl Bar _ '�� "CERTIFICATE OF EXEMPTIDN FROM WORKERS'�'"�' � -" -���--�- ---� " "" " '�NO:OF BtOGS.- -------� -} �+REST- � SIZE Of lOT NOW ON lOT � CRO55 ST.Hl�Jtl ICIlOE� & Golden�Springs " `���` � ��COMPENSATION INSURANC£' ` �' � (This secNon'need not be campleied if ihe peimit"is for'one .... . ._.....- 3S7F7�.... -.- . . .. -- - -�' SH ........� ASSESSOR... _. .� . ... . . . . . .hundreddollars(EI00)orless.). � ., , 1RAQ � BLOCK LO MAPBOpK'���� ' <` 7AGE PARCEI� . . .- , � . -.- OWNER- �Ii�' ANDFN GEYJ[TP _- . — USE ZONE �P TE`. 967 9541 .. . , .- . . . _ ..NO." . I cenify tho�in ihe perlarmonce of the work for which�his � ' � 3 ., . _ _._.._ ���" permit Is issued,I shall not employ ony person in any manner __. ' -- � SVECIAL---- - ---- ---- �- 'O `- ADDRESS-�P.O.BOX 33Z9 � - ' "�- �-�-- - "�-�� Ul/'t� CONDITIONS � so as�o become�wbjett to the Workers'Compensa�ion laws. :V _ ' c�n. _ Covina. - - --- ._ nP.91722 ---- _ -, ---.. . . _. Im �e ' "� �ApPlicant � " ARCMrtECT TEI.44cr'4O'�3 !.. DiSTRiC7__ GROUP iYPE_ i _ .FlRE_ .PROCESSED BY � I i10E TO APPLICANT If� o(rermaking tbis�Cerlimre oi ENGiNEER�V0$Z7Yly � NO. CpNST. E emption, you should becoma sub�ect��o'the Wo�kers' " N. F'1TS � A�'Cd ld ' (/� Compensotion provisions of the�tabor Code;you must forth- AD�RE55 �� -I�----- ��3�� -� - � ---� --�-1-�--- ����� d with comply�wilh�such provisions or this permit sholl be" :��-� ��TRAttaR �� �ID.IN G�� � 44S�4O73 $TATISTICAICIASSIFICATION APT. CONDO. ' � IZ , deemed revoked. ... . . . . . ... . .... �...,��t � .. _ _ . _...._._ _- --...._... . . . - - - ., .. � LICENSED CONTRAGTORS OEQARATION-�• - � ---- - �----�- - VA� -� �"����� ue. -�37158Q ' �+�NO. � � PWell.UNiTS� .. • 1 hereby affirm that I am litensed ander provisions o(Chapler9 ADDkE55 NO. � 1 (commencing with Section 7000)of Division 3 oF rhe Business and -.-_.._ .. . ...... .....----�.-_.'--.." '. -_ -. .. _� `��R MAP � .-- --- - -- ...._ tIC-- � Professions Code,and my license is in full force and effect. Gltt M55 B - "BK:� � ���� � � �� �VAIIDATION � , . . . ..,. ... . . � ' . . _ : , . ., 371580. .�. , .. B.,.., ._ .... �.EF1446 -- s oR°s------- F°:��oEs 1 ___ �"oNe�` � � , License Number Lic.Class ', . • � � � � � . THE ADIDIN C��iJP. . �".6-19-86 ---- vniu�noN_.._:. .---. - --,- - - ---..... oFscaivnoNOFwoeK SiT�gle f�ni].y--- -- N�a' -�C] . __ , Conlroctor� Dote A9D � S 54�0�� � ' f=��� �.v f1� f� 470-SF _........- - , �I om exempl under SeC: . . -"- - ' " ALTER Q �� �� r e e • •�� � . � . . . _ ..._.._ . . ,...., ; 0 '- . _ B.BP.C.f0�IF1f5 fe05on _. . REPAIR s...___.."" '_._ _.. . ."'_"_'_'._ "_...-..."'_'_ _.._... . -- _- - . ... USE OF ' I �2 3 i,1 6 : . Dale:.-..._._ EXISiINGBLDG. DEMOL Q .. ...i�_ ..-__..._._ . .__ . � .-" Signatbra ..... ._'.-__--' . . .:: ._ .�. APPIICANT TEI. � "�•. �.� b u . FRINT No. FlNA� � � OWNER-BUitDERDECLARATION . _ _ -�-DATE;2.'��-(�.'.. ____�. ._"--0,�' _ , � .. _ _ . ._ _ _ - . . -I hereby oilirm that I am exemp�from the Comractoi's License qD�uESS p"S �Ve flNAI�'� . C ' �8 6 ' � � ,,. : . �nw for�he following reason�Section 7031.5,Bvsiness and � -- .__ __ .. _ �Tesslons�CodeJ:. .. -'`... ._'_. . _' .. ... . . vRE NT BY�.. ' . BUILDING � I, as owner oi the property, or my employees with ,, nDDrtESS ._. ._.- . - --- • - wogrsostheirsolemmpPnsaticn,willdotheworkond - • � . �. IOCAUTV �' '�y �n-.. r.. • ��• .� � Ihe strocwre is oof inte�ded or offered for sola Sec�ion "' ' ' � __.._'70A4,Business and Professions Code)._..�-.-(.-.. ._._. MOV�NG--..�� .•... ... . _� . .• � TEt.� ` '--'-� --. ..-- - -. __ .. .._ _. _ ' . �}'�'�.L!-Pt_"` '. I,as awner of ihe ro eN am exdusivel contrauin CONTRACTORl�� •� � �� `•'. '' � � .� P P Y. Y 9 _.- .'-. .._. ...- --'-'.- - --- --- 4 . .. -' `''' - --� . _. '� $: .o.�-�o } i wilh Ilcensed cororo[tors to mnstruU fhe proje[Y($eo- pD�RE55 • �^ ;i � �ion 7044,Bvsiness and Pro(essions Code�. �'� r� � 3 3 6 0 Q ' ������'�"� ��CONSTRUCTION IENDING AGENCY ' SE�BACK "YARD �Hw7' ' 1OiP'P OP uNEfROM •. yyIDTH i ' � � � ... L_�lti.� ��i . ��.. .: .'' I he�eby affirm thal thera is a mnshuttian lending agency for pkONi . _..._._.. _._. ' _ ---.%�.>..'�.- �'--: .__.:.i j--.�:+'�.! _o_o J J�i�Q c=.i ' -�the performance of ihe work for whicb this permit is issued �- -� -P.C---�- -�- ' --'--'�—--�-� '' - - � (Sec.3097,Civ.C.). SiDE � � '. O S�2-8 6 _ P.L. . . . .��. .._.._. ,' .- . ' ... ! _�._� ;._ . ..._ .. __._ . . . . . _. . ._.. . __'_ __.___ _._ . _'—._'_"_... Lender's Noma f nnti nanf-al Tl l i mi c � .-. ' - � . - , .. . ' IOPAA Ref.k ' - . . .. � �' ...-- --231-S. La5a11e,Chicago IL60693 v.c.-Fea s -�231. �rm'1 Fee 325.50----- - lender'S Address � � -1 teriify�hat 1 havo reod thh opplication and:fote Ihol.the -.-.- ---'-- ._.__._.____-...._ �seonnce Fea,-Q•50- ---- LDMA P/G N�- - -� � '-•--'..-' - - - ��� -- - - obave information rrett.I agree lo comply with all Co�nty in�asrgation Fee � . . . ordinances ond a� .laws rela�ing fo building connt�uctioa, . � �' ,. .._... . ..... '__._ __ __._._ TololFea- 336.00..-_.__'; �LDMAPerm.N_. . ..-. . ._ . . . . . .._'..... and hereby a o" represen�otives of this Co�nly to enter � . . upan tha n d property for Inspetlion purposes. _ . .., ..._' —_._ ._ _ ._ _. _ .._ . � _ . . .. _ . ._. . .... _ , -- . . . - ' --- --' -" '-' , J� SEE RNERSE FOR E%PMNATORY UNGUAGE ..... . __..._ .. . .. , O ....._Signarure of ApplicoM or Agent -.-.... . ' oro ' __'_._ __.._. ......._ ._ _ _. .. . . _ . ._ .-. .'_' '.-'. --'. :._ .�_ _ � : •i z �.� ;. � -- ° �� . .v- ..� +'p �� o �� --��1� •,t � = � �� O 4 Q '7 '�Cl Q� �.� 0 � � .� �� 4 � O � t�_ ✓�•� t0, �O p � � .� O � � �. T �V+O . � Q. O ' n7 p 3 �O � p ,n N O W Q _ �O 7 �,t O,q ��� j 3 m � q T; O � O '7i9. 7 - CJ -N,� e� r � o � a g-� 9 � a o'o � � y r p p., o .p u� c n � .. j a o c 7 S � m �• � � p � o: ��. � _ -- � p w , � O � �' < ��'. O .i �^ n m �T1 W`C 7 u' •� P . 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