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HomeMy WebLinkAbout1097A 1098A . --�- - ._ ..._ ._.__...---.. ._.._ .�_,...._ .__...._..---- . ___....._ --.... ....___. ._._ --� ----_ . _ WORKERS'C0/v1PEN5ATION DECLARATION ' "" ' ����-''�'� � �'��-'� '�'' �'� ' ' ._.. ' . .� . . . ,:. � - '��-�------ -- � . _ .. _ , nsur66or�afcerlifco,ieofWokers',Comp�e�n,csa�oolnsurane" � � APPLI�CATI�ON���FOR��BUILDING-�PERMIT ��� o"r o ce�7 iEed_5o6��h�p/�f(Sebto3eooNatio�i�aide • 30/B COUNTY OF LOS ANGELES ' " BUILDING AND SAFETY � ' 3NIC U 4 - PolicyNo. . . ComPany � �-- -"--�---.. __._ . . '. � .. . � Ceriified copy is hereby furnished..•. / FOR APPLICANT TO FILL IN BU1lDMG � . •� ADDRE55 840 N. Feathes�nood Drive ❑ Ce�tilied copy is filed'with Ihe couny 6bilding inspec• " 6URDING Q Q jQ. Feathe,nr�ood Drive � � � .�tiondepanmenl. . .�� . . .` ADDRE55 ' � . . oore 6-19-86 � nPP�ico�r 'rHE AI�IDIN C��(JUP aTv Diac�142x1 $ar Ziv 91765- iocninv Di�roflc3 Bdr �� `�'CERTIFICATE OF EXEMPTION FROM WORKERS':� -� � � - ----� �--����F BlDGS. - --�� � NEAREST. ' � '�•'� COMPENSATION INSURANCE�. ��� _ SRE OF LOT --'� � --'---. NOW ON lOt . . .. _..� ASSESSOR.HiCJll.KTYJ}��&_GOZC121'1 $prlI'Yj ._.T..-.... . S _ � (This�section need not ba mmple�ed if the permil isfor one iRAR 35761-. B�� �Oi Mp.v BpOK�� PAGE, PA�� hondred dollars(5100)or less.) . . , , TE� � �. . .. , � . . , . . .. .. __ ' OWNER ����+"ANUEN�'GF�UP' 'NO:'_Q( _ �P . ��3 .. . ; } , 7 9541 u oNe I certify Ihat in tha performance�of Ihe work for�which this �/ � , _,. __. . __.. ._.- _ �ermit is issued,I shall not em lo on erson in an manner � - SPECiAI�� -� ----� � p P Y Yp Y ADDRESS� P.O.-BOX-3329-. -.___._.______ _'...." C CONDITION$ � . . � sb os'Io 6ecome subjecllo the Workers'Compensa�ion Laws. � �-V ... �, ,... � � � ,. ... . . . . ZIP__. ; .. .. _ ._. . . ._ _ . _ . __ __ .. .� - an_ ._.. � _ ,. e � � � ' AppllcoM ' ARCM�TECT OR '�`� 445-4073�� ..wsru�cr . .�aour TYPE , . . flRE ,_ _,PROCESSED BY � �p1� T�CE TO APPLICANT: If,�oFler moking Ihis Certifimta of ENGMEER Dave Szany ATP, NO. CpNST. �oy� V �mptton,�you'should become svbject to the�Workeri �� " l ' �W � Compensation provisions of ihe Labor Code,you must fonh- qDDaEss 314 DT. F].x'St Arcadia 910�6 ..I�._. �-3 _.. �.._ �.�-- . �---�� � - ,°-„ wi�h comply with.wch provieions or ihis�.pe�mit,sholl ba -� TEL.- � ' STATISTICAL QASSIFICATION � APT. CON00.� ;_ deemed revoked. �,.. � � ' � , � �� ��IN C'�P -- �-�- - - � - , ,�. , . ...... .. . CONTRACTOR NO. -_. _ ... � LICENSEDCONTRACTORSDECIARATION� ' -- � -� --��- --------�- �-LiC.-- �u NO.����� -DWFiL UnliTS I hereby affirm thot I om licensed onder provisions of Chaprer 9 ADDRE55 � �Ve r,o. 371580� ' , , , . (commencinq with Section 7000)of Division 3 of Ihe B�siness and - --UG�.�� $ ��R�P � ..._ � _ .. _ ...._..._ _. _' ._ . . . Professions Code,and my license is in full force and effeU. �ITY CtA55 � � �- -� �- '- � - �� ' ���� - �VALIDATION .� ;.. . .; 8K. PG. � . .. ; � � � ,.. , ' SQ.FT.1'�H6-- NO.OF NO.OF_ 1 CHECK . �, . . . LicenieNumber�,3�J SO ' �iQCI055 g l SIZE�� STORIFS �� �� FAMILIE$ ONE��� , . ' ' ' ,. .. �S � ..�: .., . .. . VALUATION _ � �� �9.7� . - �ES�RIPTION OF WORK... S11YJI.A f�IL1I_y.__'_ NEW.._fl _. GS f 3ZO ;.. . �� - . - ' .. . � co���aao� 'tS�F �NDII�1 GI�UBa�e '6-19-86 _ noo � s #�. . • �.� ❑I am ezempt under Sec. - - G3L'd e 445.SF--. - A��R ❑ ----._' , .. ___ -' REPAIR . S.._ .. . . •.Z G a EJ.S'. -. ____... . . D � ...._. 8.8G.C.for�his reason . _.__ � � � � -.._""' ... ...__ .... __ . .__' '_Date: .... . � � USEOF DEMOL ❑ � . �. __.'. !_°.G�.E�_FjJu ' EXISTING BIDG. � . •. ' . ..._ APPLICANT t�' ��,F'[�] G�JP TEL. FINAL . .-.. Sigriature -..._ . . -..-��"� '- DRINT r,o. � �� � 0 3 2'c=S 6 , OWNER.BUIIDERDECtARAT10N . ...DATE ._._� . .... .. - .'--._.__.... . . --• _. ._ _ .__... ..... .. .. . - - . -I hereby affirm thot I am exempt(rom tha Contraclor's license A$ c1tJpVE .� . ������ ��� I A�DRESS FINAI . . •, � .•. .. .,�� ' w for the foNowing teason(Section 7091.5,Busfness and g _,__._ -__._ __ _. . ,_ _ fessions Code)�. .�. .__ -_.. ... _ .. ' - � - pae Nr y �- -�- ' , . . � ewio�r�c . .. I, os owner of tha proper�y, or my employees with ADDRESS � �� - � -- - . . . . " , � . .'-, -�vJogei es��heir sale campensaFlon,will do the work and �� LOCP.UIY � � 'r� ��' the strutture is nol intended ar o((ered for sa�e(Settion ' #�s .1 10 .8 _ _�-._ 704d:Bvsiness and Professions Code). � � ' �---� MOVING- '.... -�----- --`-'--��---'-TEL:'.. �- �' ' --.._ . . . .._ • e • �' 1,as awner af the properry,am exclvsively toNracting [ONTRACfOR NO. . : ..._--'-+ , - with�licensed toMraUors to conziroct the projett(Sec- -� �- ----.-. .__... _ _..__....--'-_--- -.--.-.- -_- ....... ...... .. .._.._�_- n lion 70E4,6usiness and Professions Coda). ADDRE55 • ' '� � _ REOLIIRED_ IOIALSETBACKFROM.- I ..__. . _.__.. . _'_�•. . • , ' 0..��90 V� , -- ' � �""" CONSTRUCTION LENDING AGENCY�--"�"-�-� � -� SEi enCK �YARD� MWY��- pROP.LwE WioTH . , -�� . • O O c:�-�� :.: . ;. , . I hereby offirm that there is a construttion lending agency for pqONl -�•� :�•.' .'�- -�. •� ...��.2.2��b . iha performonce of the wo�k(or which this Permi�ie iewed - -P.L ---.... ."'-- '-- -- •--- -�- --- �- -'- ' ... - ..._ . . -.., .... : -�--. .. - . (Sec.3097,Civ.C.). SiDE � ' �;a•;`,�t y . . . . P.L. _ . .. ..... . . ... ..1 �'' .. '_'. . .. Lender'sName CAII�l.T12I1�'3�. I�.�.111C)15---� - --' �� ��^,.ti. . ' '. � � �. IDMA Ret.M n ,., ' . 23].�.5.-Ic't Sd1.12�C17.1.CdC�O IL. . - P.QFeeS' .E)S '• .. . Permilfea ' � �.•.•'. _ __ .... . .._ ._ . _-' . , tenders Addrass � 0693 .�- _ �, � _Lcertify thot.l have reod this applica�ion and stv�e thaf ihe . ._-'.'-'---`�-- -�-�'-� laeua�m Fee . . . .. ., �DMA P/C q-- .._. . . �-..---�---"+ ��� � � obove informotion' corrett.1 agree lo comply with all Couny invesigoiion fea � � ordinonces on t e laws lelolin9 to building tonatroction. _.._.. _ _. . . _-_' ..._ ._. ._. To�ol Fee-. - .390.00 -- 'LDMA Perm.N � . � .. . . .,, ''' ond hereby 1 ri e re rezeniarives of this Covnty fo eMer � upon the o e ' ed property far inspe<tion purposee. LDMA - " . ., �S7S-.. . . _ ..... . ' $3S.' ` .__._ _.. _._ ._ .. ._... -. ... ._..._ .._ .._- '--" .--.- ... .... ..--. - ._._ . _ . ..._ .. � � �� SEE REVERSE FOR EXPIANATORY IANGU�GE : ___ _. . . ._..__'... - ._. __. "'.' -.... O _.____Signa�ure of APP�mnr or Agem - ... . Da .. _.. . . . __' .__.. . __'-_-.___-___..._.,, .. .. .i.. ..._ ' t i �I r i O' ""_ ' "_ " _ __.' O O_ ��! f�x o o � : u' o �o 0 o n� ��_ �. 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