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HomeMy WebLinkAbout1079A 1080A (5) WORKERS'COMPENSATION OECLARATION � �,�„offirm that I have o cer�i(icate of�a�,e�,�o,��� APPLICATION- FQR BUILDING PERMIT inwra, ora certificata of Workers'Compensa�ion Insurance, � - • or o ce�tified copy�hereof(Sec.3800,Lab.C.J �3WCOQ5-279-0004 Ndt10T1W].d2 30�A COUNTY OF LOS ANGELES..,,.• _ . BUILDING AND SAFETY Poliq o. Compony � Gertifled mpy is hereby fumished. FOR APPLICANT TO FILL IN - nooeess 737 N. Feathexr�,00d Drive � Certified mpy is filed wirh ihe counry buildtng inspec- suuoiNG']3'],N. .Feathexwood Drive � tion deparlmenl. _ ADORESS IODUTY-j�1ffiCbTY� Bc1L' 6-19-86 TH� ADIDEN GROUP DSc�IIC�TYZ Bar 91�J6S NEAREST pai@ nPPu�a�� . cin nr ceoss sr. � . CERTIFICATE Of EXEMPTION iROM WORKERS' NO.OF BLDGS. ASSESSOR � . . COMPENSATION INSURANCE SIZE Of lOT NOW ON LOT MAP BOpK PAGE PARCEL (This section need not be completed if tha permit is far one 3rj7()]_ 6$ USE N rn,aP /� 3-3 hvndred dollars[5100)or less.) - 7RA ' LOGK � _� NO. - "TEL. SPECIAL I certify�hat in the performance of rhe work for which this OwNER �� ��N �� Na967-9541 0�''+� CONoitioNs e�, permit is issued,I shall nof employ any person in ony manne� � - � � -.-.-- . DIS7RICT GROUP TYPE FiRE PROCESSED BY Q so as fa become subjetl lo the Workers'Compensotion Laws. A�DRE55 P.�. �UX 3324 - �� coN E U . �3 Jl� �f a �'te APPIitaM � CiTV � -' - ZiP ZZ��. . '. STATISTICALCIASSIFICATION APT. CONDp. O ARCNITECT TEL. aTICE TO ACPUCANT: If, a(rer moking this Gertificata of ENGWEER ve Szany AIA -- - No. 445=4073 nqu No. w `emplion, you should become subjett to the Workers' �DWEtI.UNITS �� �Ompensotion provisions of fhe Labor Code,you musl forth- ADDRE55 314 N. F']SSt Arcadi.a �91006 SEWER MAP � wilh comply with s�th provisions or ihis permit thall be 7_ deemed revoked. , CONTRnCtOR �� �IN '�U� NO. BK PG, � VALIDATION — IICENSED CONTRACTORS DECIARATION �ic. I hereby affirm thor I am licensed under provisions of Chop�er 9 ADDRESS �13 c"ikJOV2 No.371580 VALl1AT10N �� O 7 9 A � (commenting wilh$eclion 7000)of Divisio�3 oi ihe Business and LIC. � Profeuions Code,and my Ilcense is In full force and effect. CITV �yp,55 B. S 65,320 . .�� � � �2.� licenseN�mber 371580 �;c.e�oss � S�EFi�'7H6 sToe�s FaMi�Es 1' CO EK TEIE ADIDEN GRDUP 6-19-86 DESCRIPfION OP WORK Sirigle fa¢nil.y N�v s � °2 6 8 6 5 conrracror oote O - _ ❑I am exempt onder Sea G3L'8 0 445 SF -- - - - Aoo "°2 6 C 6 5 u ALiER � FINAL �_.Z�_ 0 8.P 2-8 6 B.BP.C.for this reason - �-- -- - ----� DATE � REPAIR USE OF DEMOL �t�' E%ISTING BLDG. ❑ - BY AL � � SignCture APPLICANT TEL. OWNER-BUILDER DECLARATION PRINT Sj (',�[Jp NO. - I hereby affirm that 1 am azampt from the Conlracror s Licanse qDDRE55 � �OVe -►. ... .. ... -. . _ ='-1 0&0 A . Law for ihe following reason(Settion 7031.5,Business and � �fB3sions Code�: ' PRESENT : •� ' "•' ' �r o s • D I, as owner of Ihe property, or my employees wi�h ADDRE55 ��', ' "1 _ 1',- �� 2 �' ����" e , / wages as their sole compensation,will do the work and .c , ,.,-� •.� , y I���'i n n �� the siructure is not intended or oifered for sale(Settion ���ITv -'�•� .o=� •-� .::,i:��•�, ��- 704<,Business and Profeisions Code). MOVING � TEL. � • e��Q G O� I � I,as awner of 1he property,am exclusively tontrocling CONTRACTOR NO. � � with licensed contractors to construct tha project(Sec- qDDRESS ��'2�—8 6 tion�044,Business and Profeszions Code). - � REQUIRED TOTAL SETBACK FROM E%15T. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY ppOP.LINE WIDiH (�'���_`�- �,.1^.� � I hereby offirm thal there is a construction lending agency for F�tONi - . , -' ' ' `"` -' �, ������ the performanca of the wo�k for whith this permit is issued v.L '.��-- ;� ' . tSec.3097.CiV.C.�. SIDE �^�'.; �}il;t t'S�'��y[� ' . P.L ' 1 ��`r . . Lenders NomaContinental Illirnis _ ������ � Lender's Address 231 S_ LaS3112.Chica�60693 P•C Fee E . Z6a.65 permir Fee 37 .50 ' r'�� �r. `• � 10.50 �'" - I cerlify that I have tead this opplimlion and srofe that the - �� issuance Fen �� obova information is corrett.I og�ee to comply with oll Covnfy Imear�gor�on Fee � ordinances a rate lows rela�ing to building cons�ruc�ion, 390.00 � and here6 a orize represenfalives of thls Co�nty to entar Tofal Fea iupon Ih a e• tioned property for Inspectl��f . ���yy�� i ' v ��� —SFElIEVQRSFFON EXPLANATORY UNGl1AGE 35 Signarore of Applicont or Agent Dote . . . . ._ . . . . . . .�t � Z o ,�. ' o • . � ,i � � _...- � � � n, o ` '1 '; G� ' o m � ', , G� Q 1 � � ,.m � o. d � Ci a � nv m n- ° � % o �? � '�o . p � ;N. �N' A,. � G 6 %" � . � `O � � �° �-o 0 3 �� c `� � + ��r -n V+� � �� � O.O � ¢ �� Q' � �1 �,•, + � N b. p �+` i0 7 �u 7 '� � ~. 1 . 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