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HomeMy WebLinkAbout1121A 1122A , . .. .--- _ ._..._. .._,.._..' ... ._. ..__. ._.... ..... . .. ._ � _.,.,: , . . .. -- .. _ ..... -- � --- --_ . . _. ...-- �- --.. .-- �---._... .. - WORKERS'COMPENSATION DECLARATION � •: � "'� �, . ' 1 hereby�oiiirm Ihat I have a ceriificote.of condeat to se�f �-----����-��APPLICATI�ON��F�R�.BUILDING PERMIT����� ��,�. insure,or a ceriificate of Workers'Compensa�ion Insurance, or o ceRi(ied copy thereo((Sec.380D,lab.C.)� "" ' --��� - '" " � ..._.. .. .._.___� �" '° 73WC005-?t79-00004' Natioirwirle 10/B COUNTY OF LOS ANGELES BUILDING AND SAFETY ' _ - - - �. Pp icyNo: ompany - -- � - -- --- a ; ,• , , BUIL�ING ' - ' Cerrified copy is hereby furnished: • FOR APPLICANT TO FILL IN ADORES$ ]7¢ N. FP3�1eYW�OC1 DL'1.V � Cerfified topy ii(iled with the'county building�insper � BUnDwG 774 N. FeathPy��ood Drive � ' � � � - - �'�Hondeporlm�M.�.'. � .. .�. ,. ... ADDRESS . . . Date,��.1E1-�.9-SE•.APPlicanf�-...THE.�ANDIN�GF�UIIP aTv Di�noYYl Ba� zir 91765 �ocnutr Diairo�l BaC ' '. '��CERTIFICATE OF EXFMPTION FROM WORKERS" �� ��- �- - -- -- ��-�-��-� - �--� �-NO.OF eto�5:�- - - -- . NEnREST � __.___.. __._ � � � � 'COMPENSATION INSURANCE '�• � StZE OF lOT NOW ON�Oi cr�oss sr. Hi h Rr»b�&�Golden T� S � (This SeElion need not be'completed if fhe�permit ii(or one - -- - - --3rj76].- - -- - - - 18'- -- ASSESSOR , - - � � - � �-� : hondred dollars(5100)or less.), . ,, , 1RAR BLOCK l0T_N Mqp BOOK' -�' � PAGE� PARLEL � . . ;. .' TEL. = , - owraea THE ANDEN GF�IIP -_ruo.967-9541 . USE ON N✓+P ,/ I certify that in the performance o(the work for which this � r10. ���3�'" � ' ' } permit is issued,1 sholl not employ any penon in ony manner P.�.$OX 3329� �� �- s�ean�.-�� - ;.� � • -� � � ��- -- . � . a so cs to become subjecl io the Workeri Comp'ensotion Lows. -- ADDRESS -- . . . . ------ --....--- ' (I(lO CONDITIONS � ' ,..._ ' 'U . " -' . Cov' 91722 _° ,na . .. ....,.., . an . .. . .. ... ..ziv.... .. . - -, -- � te'..� .� ' � APPlicant ARCHITFQOR TEL ;� . �TICE'TO`APPIICANT: If,�ofter mokirig this�Certificate of Lk3V2 SZclTl AIA N0.44Jr-QO73 � DISTRICT_ GROUP_�TYPE ,._ 'FIRE FROCESSEDBY.. lemp�ion, you should become'subject'to the Worken' ENGiNEEu /�,y��OrlST'��} Compensalion p�ovisions of ihe Labor Code,�yoo musl forth- ADDRE55 ' ' ' _.._l� ..._1J�� !" �� ��d PY P .Permit.shall be .- --- -- �---- - - - --�-. . da med�evokedh such rovisions on fhis• , �ONTRACTOR ��+ ��� G�� , ION ; � APT. CONDO: 1 Z ' � . . NO. , ...... � � '."" LICENSE�CONTRACTORS DECLARATION� �•���"� _. _ . . _ _ _ ___ _ LIC. STACTI�ST�ULO[1A551FlCAT -DWELt.UNITS �� , I hereby affirm thol I am licensed under provisions of Chapter 9 ADDRE55 � �7pVe r,o.371580 (commencing wi!h Section 7000)of D�vision 3 of the Business and _ �R�P � � � � - ____ _. -_IIC.----$. . Rofesslons Code,ond my license is in full force and effecL Ciiy C1A55 � �BK �- �� ' �- � -� ' YALIOATION "'---, iicendeNumber37158Q,t lic:Clau'`�•$'�' - s¢eFT� 1446 sroRs Fa°n�°Es l oNEK �� . . VAWATION..__..'._ _ ��� z� ��P.�rA-- � ��ZF�F'ANDEN GRUUP F)ZJ�HFI�, -- DESCRIPTION OF WORK�Sl le famil. -- "�-�� � �� � � � �� � Contractor Date a� � f 54���� ��• e •'��-"' ' .. . . �I om e.ampt onder$ec _ __ ._._. . ' . atTER .� i � �_��. � �.2.�����_6�._.' . � . .,.. .. _ , ,.. B.BP.C.for�his reason. . � . . ._.. REPAIR..� "S. . ' .. . _. _ ._ . .. , � . ----.._. . . -- --oore: --- ' ' use oF o�a ❑ � i .A 2�1,1 6� � EXISTING BLDG. ... _.. .... ...... . .... . ._.i � � ' � -- �- APPLiCANT TEL. - --Signature � .. .. .. . . . ... .. --- pRINT �� �IN � No. FINAL p 0 E.2 2-8 6 � OWNER-BUIIDER DECIARATION ...DATE �.Z,��T�i b'.., ..__- .'-- ._ . . ..____..._.. As ahove _ . _ _�_ -1 hereby offirm thot I am eKempl from the Conirador's License . _ . 'aw for�he following reason(Section 7031.5, Business and ADDRESS FINAL ' � `-�'� '-" ' ' • : ' bfessionsCode): _ . .._. . .._....'-'.._ ..._ _._ ....._` aRe nli :BY - - � .. ..-_ .. -_ "�-.�,i BUILDMG ; ' ; � I, as owner of the property, or my employees wilh ADDRE55 '� • '� ' ' -= wdges as their sole compensaiion,wiii do the work and � . " , � ' � � �- ��-�" - '��"- . ""�'-"" �'` �i i��,c�.n �� ' the strutWre is not inlended or offe.ed for sale(Section ����TY _� - . i - - 70d4,Business and Professions Code). .. .. .-. .- - MOVING-- -� -� -- ...- TEL.---. . . ... . , ...- ---.... .. .�'-.. . . . .• i�• •.• • r � - � I,as owner of the property,am eztlosively comracfing �ONTRAROR NO. � - :�. � -wirh�licensed conrractors to consirvct the project(Sec- -.-._ ...__---.--. -.._ . . .. . ..... . .. . ....- - --- --.. _ _.. ...-- --. .�_.._ .._..1...�-e 3J(a 0�-�--.- ADDRE55 tion 7044,Business and Professions Code). --- � � _ � " "' "-"CONSTRUCTION LEN�ING AGENCY "" � �--- REOwRED._ _ioint SeienCK M_ xi ._ .. -� ���• .__._ ; ._. _ -j.•-A J,j G C O�czi-� � ...,, YARD HA'Y � '- SET BACK PROP.IINE- WIDTH _ � • I hereby offirm that there is a tonsvuction lending ogency for FRONT �� �� t^ - � ' � ,_ i�:.'!... i --.%�'� ','� ��C z �Ihe performance of-Ihe work for which�lhis permil is issued - -- 'P.L-" �' �---. . . . - -- --- - - - -- '- -�--- -..._. . -;. .. '�8.6.." ($e[.3097,Civ.C.J. SIDE . ' '' ' -- � ' P.L. _ _. _.._.. _.. _ __., - . . � lender's Nome Cf1I1{'�P11ta1 Tl 1 i mi c`__.._ . . ^Y�.' - - -._._ . .- _- .-_--_" - (pMA Ref.M � ' � - �. ' - - - --- --231 S.-IaSalle,Chieago-IL --- P.c.F�s231.16"'�' Pe�mie F« ---325.50 ,.- ,... , � lender'sAddress � � � : .� � � �i ' .I tertify fhat I hove read this applitotion and stafe ihot t e 69.3._ _ __. .._ ___.., . Issuonce Fee- � ], . - LOMP.P/C 1f - --------. ,- .-_' ___�_. � ���� . � abova information is ecL I agree to comply wi�h all Counry Invesriga�ion Fee . ' 'i ; ordlnances and S e I reia�ing�0 6uilding construction, 336.�0 ' �' ' � _ _ _ . __.__ .___.._. .._'._. ToiolFee - . ._ ."' ' LDMAPerm.#�-.._._ ."._. _..__ '..J.._._._ .. :... .: ' � and hereby a� riz epresenta�ives of this County�o enter � � �, upan the ob e- I d property fo�inspeUion urposes. � I ___' __ . _._. . . ._. . . _._ ,..... ...-' _._.. _. ._ . -. _. ' ' '. ' _._. � �, � SEE REVERSE fOR F7(PLANATORY UNGUAGE � � � Signalureo4ApphcanrorAgen�. _.. Date- ._ _ ' ____ _ _ .-.-.__.-__ ..._ .__ . ._ ... .. .__ �-. .. __ . ___ '. _ _- � -.'. � ' _'__._.. . OI � ' C`. . TT (�= r T T (/� T yO 'O V1 T� -G7 G�. _T '_' �' T. �1. > > o 0 o c � o o ° �o ., o o n� ��n � � 1 --T--- ;- --- -�-- o 0 - m o � N T T � 3 a- � �o n- o � ,�o, n � o. a o o i� i o i ^ `° � ' a ,c `D o ° o D �o 0 o L?•, �o' � � �' I , -Z x �� _ ,r� v � `� •o F; �o � o in . 'T �3 � o Q c ? w � o , � Z� o� o o � ,� �� � N � O - � N -G < fD S�; ��� '3 O + 9: m C N O � O.O _. ./p �n ..l � ID � � 7 - ��^ 7 3 ��O _. p��' � a � � � ��� � " � � 1D ° � , ...;o -N ;, m' � '� --- � � '' A� �� 1 � d F _ _ _/ 1 I•' 1 � N `� � � O � . ._ 1 I .' = r N �. � G.�.� 6'� a� . , ' � o �A I O , � [: .'�) ' ' M � D � i �^, � � � i � I - ' � 2 �' 1 , ; O i; A I �'j � , S� ` ��, , _ � � _ . , o u. y � � � � �. •. , �- ' , � ;'��- � � , - • ..' -- - 9D+ _ ' . . i . �g' .. 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