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HomeMy WebLinkAbout1091A 1092A ., . . . - -�--.__---- ._.__-. .... . ... .... ..._ ._ ._ _ . ._. _.__..._::_ . ._._... --- -__. .. . WqRKERS'COMPENSATION DECIARATION V ,� �� • '' ' � �� ' ' ' . � 1 hereby o{firm that!have,a certifico�e of consenl'to self .... _ ;�5�.e,orocerlifimteolWorkers'Compensafion��5�.o��e, APPLICATION FOR��.BUILDING PERMIT - or a certilied cop thereof Sea 3800,lob.C.) .. . ". -- �- ��--`-- ..... ... - - - ---� .. - _.. -..-'- --� �:�13WCOg�279-0004 Natiornvide 30/A COUNTY OF LOS ANGELES BUILDING AND SAFETY � PacyNo. � � ompany ,. . BUIIDING - Certitied copy is hereby furnished. �. FOR APPLICANT TO FILL IN qDDRESS $02 N. Featherwood Drive � Certiiied copy is liled wi�h Ihe'covnry 6uilding inspec- " '" BURowG � � . tion'departmeM.� �'' �'� �'- � �� � ��' �� � ADDRESS $02 T]. 1'' {�12I.�IJOOC� �.h'1V2 ' � Dd�e 6�19-86 Applicont'.Z�.� C'� � CITY D1dTCY�TY� Be1r Z�P 91765..._ -- -� LOCALITY D1.c�I[�DTY� � � ': ' . � �����CERTIFICATE OF EXEMPTION FROM WORKERS'��`��'� -- - - �-'-����'"" -" " - NO.OF BlDGS.- - � rIFAREST_ `,;., ..�� .,. ..'COMPENSAiIONINSURANCE'.. ." � TRA B�OCK � LO �P��•.. h Fc�b.&��Golden-Sprir�gs��---�--........., S�ZE OF LOT NOW ON LOT CROSS$T.Hlg (This section need not be'completed if fha�permit is for one �-- --�L �� - �� - 7-7 - " � � pAGE� PARCEI hondred doltars(5�00)or less.) .. „. ., . . , TE� -7� / - ow�a -� ADIDE�1 GROLJP •-�- r,o.967-9541 � `/E N�OP /"1!��C( �T .. .. .. .., . . ' ... ... � I certify'thot i�Ihe performonce of the work for whith�his permil Is issued,I shall poYemploy dny person in dny monner qooRE55 �P,�.Hox�-3329 -� s�Ec�A`... �_-- - . .--��- sa az to become subjecl to�he Woikers'Compensa�ion lews. � - ... _ ' "' ' _ . ' �'D DI7I . _. .. �/ CON ON$ !V ,,, . ' an COVin3 zir91722 _ . _..._. --; - , _ . - le..�..�"� .. - �� � aPPu�a�,� aacr,�TeRA TE�.445-4073 DISIRICT GROUP'TYPE �FIRE PROCESSED BY r Q O TICE TO APPLICANT: If,�afier making'thfs'Certifica�a of ENGMEER UaVe SZanY � NO. � CONST.` ZOriE� � emption, you should be�ome sobjett-to the•Worken' - � �r � �W Compensotion provisions of the labor Coda,yoo mvsi forib- qDDRE55 314 N. F]YSt Arcadia 91006 �� �3 �-�- /�/ - ,�-� ���� �-�- ���" with comply with.sach provisionz or.this�permiLsholl be -- - ��� �IN G�P 7EL i � T. OnlDO. � deemed revoked:..:,. ,...�.,.� ,, � . �„.•'.• .:..,..' COMRAGfOR NO. _ 1 . - � STAT STICAL QASS�FlCATION i AP '_ LICENSED CONTRACTORS DECIARATION,,i , �. � - � - ------ - -- - �- �� - - -- LIC.371SHO �'4S5 NO. � DWEIL UNITS� I hereby affirm thal l om licensed o�der provisions af Chapter 9 ADDRESS � �Ve NO, ��R�P r , . � (tommencing with Sedion 7000)of Division 3 of�he Business and ..... .. . ... . .. . ... .. .._.-.- '-' LiC.--- --�- � . __ -.. Professions Code,and my license is in full force ond effeU. C�Tv CIA55 B ' '-BK "� �" --"� '--�-- VAIIDATION-" ..,. .. . . .. . � � . . � ', .371.rJ8Q:i:: � .-., B .� __ _. �E�7HF)--� TOkI�ES..,- .. F MI�ES 1 ._ ..�ONEK'_ ' ... LicenseNumb�ei � �Lic:Claes ' VAlUAT10N � � � �n� 9 � � � � .. .:�.� . . . . ., .., . -.. ... � ... . _.. .. __ . _ . .. ,. . , , , _ oescRiarioN oF woeK 5�41e family ._. New -g] - 65,320 : 1 Con�iodor �iF. N1I�FTT� 1P D'ate 6���6 ADD � s � : 'If+ e • •2��'- . �I am eKempt Under SaC. . �. •..- - .. .. ..... . Cn-Z�a e-44rJ SF_-"—" ..-.'-' . ALTER.'-❑ : , � . .. .� �2 6 8 6���. : _ ; .... ... . . . . .. s -- ._._. .. . f iF1i5 reason REPAIR..� ��- -"' .. ... • ._- w e L 6 5 L � �� � � USE OF DEMa ❑ _... ...Si nafure ._ . . __...._.._ Date:.__.�.. ` �. _ _ . .....-�� EXISTING 6LDG. � -�--�- ... " '-B.9P.C. 0 ." ' . ' " '.. .-_""_" � : . . . APPlIG4NT TEI. FINAL ' O Fx Z��H b . OWNER-BWIDER DECIARATION _ ... _ 9RiNT . ._. . .- ---- �' - ...._ . �ATE-f Z I .•.- .. . '.._. . .. . ._ -.: ,-1 hereby affirm Ihat I am exempt from the Contratfar's License aDDRe55 � �Ve flNAI '�" � ' ' � � ' w for ihe lollowing reason(Section 7031.5,Bus�ness and ._ . .. .. . ' fessions Code):........ . .... ... .. ....__- ' � _- PRe Ni .By_. � .� �. BUIIOWG 1, as owner af tha properly, or my employees wi�h aoDrtE55 _ _.._ .... .. ._ ., -- • -�-wages es tFeTr�iolc 2ampensotion,�wil1 do ihe work and ' � �� � � � ' ' �. the strucWre is not iatended or offered for sa�e(Section ����TM ' +��1 G " � '7044,BusinessandProfessionsCode).'--�-�-'- �-- �-�-� MOVING -- �-'-'- '-- .-'. _. .TEL- . . . . �-�� - "� � ---�":- 1 . I,as owner of Ihe property,am e.clvsive4y tontroUing GONTRAGTOR NO. � .� . _'_... ._ J O O r. . _O-...with licensed tontractors�to constrvct the project(Seo- �- - --'-"-- .- . . ..- - '...._. _ _ .. ..... ..-- - -_ . ---..- . . . ' n • tion 7044,Business aod Professions Code). ADDRE55 � - •' ' '9 O. __ . _REOIIIRED.. .IOIAL SETB<.CK FR , ,CI i. . . . ��'•��i_:..5 ' �` � ��J?C'O O V �-"-"""-"tONSTRUCTION LENDING AGENCY-"--� - Sei eaCK� YnRD HWY' PROP.UNE WIDTH � _ , i I hereby aftirm thot there is a conetrudion lending agency for FRONT • '. ��.2�-�8 b -the performonte of the work for which this permil is issued ---- --P.4.---- - �--� �� ' � -� - -"- � -� - � - - -� - - �� �� �-��,, (Sec.3097.Civ.C.). SIDF . ' . . . , .. ... --- - -. . .' P.L __ . ._.... . . _ . ._ . -. '_' ' ___. _. - ' ..lender'e Name�CnT��"i�nPn1�a], I�1�S701S . : , . : .. ,. . - P.e.Fee 5...-- 26H.6S P�,m,�F�e ..-. 379.50. _ mti+n R�r.x - -� -— - , ---. - ---, .. . Lender'sAddress��1 R Ta5a11P�Chic�a�N� � 10.50_ ' � "" " ' ..1 certify Ihat I have read this applimtion and srote tha66643 .. ...�_- - . --._--- -�- _- �„�o��a F�s -� �ounn r�c M.-._.. ._ ._...___ ...� �...:..�. . , above informat' is coneU.I agree fo comply with all Counry Invevigo�io�Fee � ordinances d iate lews t@loting to building tonsiruclion, __ , .,____. __ ._._ ._ . Tolol Fee - � -� 3gO.00 ._ -�pMq perm.M �- � � � _..__ . -.._.... _.. .. .. . . . ....... �and here a o ize represenm�ives of this Coonfy to enter . upo t e-m tioned properly for inspeclion porposes. � •$75 . '' } .$3r)_- _ . .._ .___ . . ... . . . . - . . ��/� � - --— LDMA � __ .. .-- .— . . . . o �� SEE REYERSE FOR E7IPUNATORY UNGVAGf� � ' Sigria�ure ot Applimnt or Agen�---- - �-' Daie ---' ��� - """"�- � ' � ''-' - �� ' •I mT r r m T N 'n r v fn rv � _Ci1 �_". 'S.. _�. 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