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HomeMy WebLinkAbout1139A 1140A (5) . - --------_ ...----�-------.- ..._.. .._...._ ......__. _. .._____..... ._. ___.._. _._ ._.. - -- • „ WORKERS'COMPENSATION DECIARATION '� �- ���-" '��' � �' '� "�''' ��" _. ��. , � . � . . . . _ ' . , , , .: .: __.._. ..--'.. .._ . - _" ` irisuieborofcertfcateofWorkers9''Compensatioolnsurona" APPLICATIO�N_��F:OR BUILDING���P�ERMIT��� ora cen7�e3�o��5tie2�g(5��04��Na�tio�,ride ^60/B {2 Car) COUNTY OF LOS ANGELES ` BUILDING AND SAFETY .I PolicyNo.,.. . .� . ..CompanY - - -- BUtlOING - -- � �� - . � Certified copy is hereby fumished: . , FOR APPLICANT TO FILL IN qooaess 814 N. Featherwood Drive O'�Certiiied copy is filed'v+ith the-[ounly 6uilding inspec- " BUR�iNG 8],[� j�J. Feathe�.z,�ood Drive � , : ' ' � '•tiondepor}ment.� ' ADDRESS � � ',� " •. , . . . _ . . . .. � . Dote 6 ERT91FIC8A6E OF E%EMPTION F7R0 W IN �J� C�TM Dic�roIY� �3I LP .91765 ---... . loCAIIN Dic�I[p1Y� Bd�' ' � ' �; .••� � � ORKERS' '� ____' '._ . .___ .. .. -_ . __ NO.OFBLDGS. . . .-_ .. NEARFST --. . __' ._" _""_' ._:.. • ���•�'� �COMPENSATION INSURANCE �• SiZE OF LOT NOW ON�Oi � C�iOSS Si. H1 Il KIIOb S GOI-C�P.II S L'1 S � •�... ..... �..,:•-. __ .. .. . .'_ ... .._ ASSESSOR._` -- ' ^;: ' (Thiz section need not be�completed if the permif is for one �- TRAC7 BIOCK lOT NO. hVt7 BpOK� ' � PAGE', PARC�I ` � h�ndred dollars(S��)or less.) ...., , � . � �.... , . � . . . ... .� .,.. .. _...._- OWNER- � IIQ CxTX�IP_ ... .-NO:'__9 _ ON� �P .. . :I} . ..: 67 9541 �� I'certify that in the perlormance o(fhe wark(oi�which�his - ' . _. __ „__..... permil Is iss�ed,I sholl not employ any person in any monner � � S�E��A� ����� � � �� �� a so as�fo become subjett to the Workers'Compensation Laws. � ADDeE55-P.�.BOX 3329-- �-��-�� — - ---�� -- - t-rv CONOITIONS � . ��� � •-� •�V .�. .. ... .. . , , .��. , . -..... ........'_._ --- ' _-_ ' .'.". . . ' . � . , . . � CIN_.__. ' -_ _ .._ _ ... . ZIP... ._..__ � i � """��� ._. .. . .-, . �e .`..... . 'APPlicant � .. .�.,,. .,... ARCMITECTQR 7E1. DiSTRICT_,_ GROUP NPE_ . ___ RRE._ _'PROCESSEDBY. 'O TICE i0 APGUCANT: If, afte�mokin this Certitica�e of �dVO .SZc117 ATA No. 445-4073 9 ENGiNEER Y CONST.' ��E - , ;W mp�ion; you ehould 6ecome�subjec}��o�Ihe�Workeri �� Compensation provisions of the La6or Coda,yov must forth• qDDee55 314 N. F'1r5� Arcadia 91006 � - G��-�� �-3 _. �-� --� - -� - - � with comply with such�provisions or this permil sholl bo ��� � ��, � G�� ��, � STATIS7ICAL C1A551FICATION � t APi. C NDO. - 'Z deemed revoked._..�...,.. . .,.+�, ��, ' ,�'.. .�. [ONTRACTOR NO. -- - " � - IICENSED CONTRACTORS DECLARATION ��� ��'�: � �- --- ��--� - ��-- � �' - -----� ---��C- � �- � �55 NO. �� ` DwEii.�UNiTS�� � I hereby affirm thof 1 am Iltensed onder provisions of Chopter 9 ADDRE55 AS d�JOV2 r,o. 371580 , � (commencing wifh Seclion 7000)of.Division 3 ot Ihe Business and .. _._ ---- LIC. ��R�P _.. . _. _.... _... -. _- .. ' _-'- ".. . . .__ _.- -' ' Professions Code,and my license iz m full forta and effetV. qTY ��`�B � gK. � ��pG. -�� V ' ' ' ALIDATION' ,.. ... s°.FT.2375 No.oF NO.OF 1 CHEIX , _ � � .�,�/A LicenieNumber3.71 5�n liaCloss �T; S12E � STORIES- -� -�- FAMILIES � N�ONE VAWAT{ON_.__ ._. _. --. +t-s-a . .2� I ; ,. . . . . . � _.-�� G��9-HF] "...._ DES�RIPTION OF WORK Single�family- � � _ $ � . : Conrrador `�1F'ANnFTT CI3�T1P[]ote 6'080 � • . . - aarage 510 SF ADD � __,.. -•�3 1.1 2 -- . .. .- - - - -... �I am exempt�nder Sec. �-''�- "��"�"-'--��� �� � � � AL7FR � ' , '� , .,., - : . �•,� -�- ' � � -'-' _ ..,. 6.8P.C.for fhis rea5on. . .� ' _._'__ REPAIR � . s .... . '__'_..: .--,.. _....�,e J.J-�,�-�-�� � __ USEOF � __ � __.._OC;22`8G - t _.. .__._._. _.._ ____...'__.Oate: . . �EMOL E%tSTING BtDG. .......' � . . . AGPLICANT TEL. � '' 'Signafura � ._ _ ..._. . .....--- -_. � FINAL �� --'-.-_"'- OWNER-BUILDERDECIARATION PR��'�T NO. _.DATE-�IL zt' -�... � � _ ---- -- --� . -I hareby af(irm that I am ezempt 6om the Contmdor's License ADDUESS � a�Ve FINAL �� � � '��� �� ' ' w for ffie folloviing�reason(Section 7031.5,Business ond B _ . .--. „��_� �a.A. - IBSSIOnS'COdO�t.._.._ ... . . . � . ... . .__ _."' PRESfNT Y .� . ^ , BUILD�NG � ,� 1, as owner of Ihe property, ot my employees wilh nDDRE55 . � � {�' • " "�'�� �-� . _ . __ , ' -_ -' , .. . . w^ges�i!heir:c!c Ecmrcrsc7icn,•A•i!I do tha work and � ., .. LOCALItt ' tha strucwre is nat intended or offered far sale(Section . TEL. �-,• �'- � -- ��- - -"'" -� ��"` � ����"5�' "� ... _... - _ _. 704d,Business ond Professions Coda):-- -""" � MOVING' ` � � � CONTRACTOR'. ... . .. . ��-NO.t' . , -_'' '...""_._...__._..__.. ... _' ' " __ I,as owner of the ro e�t om e.clvsivel contractin . . .. a t: P A Y, Y . 9 , . ._...•. • � i�..., . ,.�. . ��JOu. . - - with licensed conlracfon-to cons�rocf the pro�eci(Sec- �� REOUIRED iOiAL SEiBAIX M . %I i. .-_..- . , ^ I tian 7044,8usiness and Pro(essions Code�. /+oDaE55 ' '� �'' � £ 6 �"�---� CONSTRUCTION IENDING-AGENCY � � � SEI BACK -YP.RD HVJ1'� pROP.UNE WI�TH � �� ,, , �r, -,� , � - 0 6 I hereby oifirm�hof tMera is a construction lending ogeaty for FRON1 _ ' 1� 'r.'�• �� � � � 1Fe performonce of Ihe work fo�which�his permit is issued ... -P.L...- . .. .... ... ... ----�-- ' - -"-.-. . .-.-".---- �-- ---. .._ - .. • ..- �. '� . �Set.3Q97,Civ.C.). SIDE - .�. , F.l. ,. .' ., . , _,._, � , . . ..___. .._ . . .._. . ._. . . lendar's Name CArit11'1P.11�1-'Tl 1 i rpi g- . � 331"12 ior,w R�t.x _ , P.CFee§ • r�,m,�F« - 474.�� � , �- lender's Address��1 �R_TaSal l E+� i a�TT� ' '�-� I ceriily that 1 hava reod.this opplimtion and s�ote that_ihe (Q(9 - ._ .__._. . .-. -- .-- Issuonce Fee.-- --�-0.$0... iDnva P/C M-- - -- . -._. . .-- :-- � '. - �-' � abova inform ' n is correcl.I agree to comply wi�h oll County Inveeligation Fee 4$4.5� ' � ' ordinonces 51ata laws refvting to_building consirvtlion, � - � - � � ..'_._' _. _ .To�al Fee-. . ... _. .IDMA Perm.k. . ..__' .__ _ . __.. ._. _ _. ., .._. . . .. . . ._ . and her I rize rep�esentetives of this County lo enler opan� e. tioned property for insperyqn �poses.` LDMA - ' $75 _ � '. $.. ... _..--. .. .. . . .._. . . . --- -- . _ y __ _ _-- . _ . 35 _ j (/ � F,J SEE REVERSE FOR EXPLANATORY UNGUAGE � � �-----SignaWrc ol ApplimM a Agenl � -- Po�a -- -' -�"-- . _.-... .. � -- ...-. . . .__. _ �OO� >> o o � o � ;' `^ o i.�o a o ��^ T�. .Yi- .Y/. 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