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HomeMy WebLinkAbout1062A 1063A (5) , . •- .. ..__ .. ._... _ ' WORKERS'COMPENSATION�OECIARATION ' ' -- _.. ._;._-'__.___._._..._ . ,.,._..._......_--..'-'- '- - -_' . _- .--_.-•.--,-__ APPLICATION�FQR-� BIJILDIN-' �� � .,: >njreby^aiiir� �hat I have o certificate�of,consent,fo.sel( ��� insur�,or a certifimte of Workers'Compensation��5�,o��e, . � G PE RMIT��- �� o�e certified copy thereof(Sec.3800,Lab.�C.)" ''�� " " �'����� ' � -� � � . GOUNTY OF LOS ANGELES � - -- - Po����005-279=0P0 4a�Nationwide' • 60 (.3 Car). BUILDING AND SAFETY - •Ceriified co �z hereb fumished.� BUIIDiNG . . - ' ' - --- --- -- ' - _. . :�. 0' Py� Y �" ' FOR APPUCANT TO FILL IN AWRE55 $59 N. FP�thflLWOOd Dr1V0 � � Certiiled copy is filed wi�h'the covmy bWlding inspeo- '---- gUnDiNG N. p.1 �T1Ve ��Iion department.'� � � - �� • ADDRESS - � . . .,:..,- . '. . ... .� '��,.. � . . �.,.. '„�.�,'�-. . : � _ _ _ __' '_ .. _'_'. .. . oa�e 6 19-86 •. nPPi��o�r ��.�� a� _. .. GITY - ZiP ' - �ocaurr Diamorrl Bar `�� � `CERTIFICATE OF EXEMPTION FROM WORKERS" -�—' ' - � - -- - - NO:OF BloGS.�-�------- NEneEST_ �" � COMPENSATIDN INSURANCE"' �'� �-• SRE OF l0T NOW ON tOi � cRoss sr. High-Kmb..&�Golden Springs -•-•-- - (This seclion need nm be compleled if the permi�is for one � �----- � �- i __ __ _ '____.3 ... ... .... .. . .. "_."_ '. . ASSESSOR. � ... " ' . hondred doliais(EI00)or less.). . . � TRACT .. BLOCK lOnN6ew��,�o� �„�qp BOOK� � GAGE' PARCEL ...� � � ' � : . . .. , . , .. .� ..�.., , . ._. _ APJDII`J GIJ�UP T _ P owr�ER--� - _-No.967 9541, us�zoN� tiv+ ; ,� I certify�hal in�ihe performance of fhe work for which this � Np. : - Q � -� permit is issued,I shall not employ any person in any monner � �--- � SVECinL•� ��---- -� - --- ---�- � � ..,.�.:.�- • � � _ 0. � so as fo betome'subject to ihe Workers'Compensation l6ws. ' ' ADDRESS��-�.�.�X 33 9� . .. � ... . .----._--� � �pNDITIONS � 1 'Q .. , •,.. ., _ . . . � ^ , . . ,,.„ . . . . � � - CITY. �.'Qjj],� .....ZIP ...7-J.722 ._ i . _ ._. •_' " ._..._ _. V '_... . .. '___ _' _ ' . 1 te ... . .,.APPtimni�, . t� ..._, _---- --- -- -- - - - • :� � ARCHRER OR TEL � �� yTICE TO APPIICANT:.If, o(fer making-fhis Cerliticola of Dave S 4QrJ��IO�J3�. DISTRICT_ .GROUP TYpE__, . FIRE _PROCESSED BY. _ , ENGMEER �Y NO. � �bmptlan, you shoold become subject to'the Workers' � -- � �O Compensation provisions of fhe lobor Code,you mosf forth• ADDRE55 314 N. F1YSt� Arcadia�91006 ..._. _J ., �-� _ �_ �_J�_ W viith tomply with;soch pravisions or this permit shall be �--- --��-- - - -�- -- � �' d00rt1BCI fBVOked. . .. ;, , „. . . �' :, '� . CONTRAROR ��' ��� Ci�� LIC: ' ATIODWELL ' i Z STA ISTICAL CLi551F1[ � ACT. CONDO� ' . . . . . NO. . � � UCENSED CONTRACiDRS DECLARATION..�, � . . -_. . . ._.. _._._ _ ._ . -'-- ' '-�-"�'��` -- '--- - � � � -` ve 371580 -" �+ss r,o. .ur,�Ts I hereby oifirm that I am licensed under provisions of Chopler 9 ADDRESS � NO. (commencing wi�h Settion 7000)of Division 3 of the Business ond _. ��� . SEWER MAP . . •,. . •. , .. _.. ._...._._._....-----..... ._.. . ..-'. Rofessions Code,and my license�is in full force and effect. Ci7Y �qu -------�---- ��--���_ �_ _. _. _ _ _ �. � . . . � . . . SO.FT. NO.OF NO.OF. CHECK BK. �. : : ; `VALIDATION. _.. Confrocormber - LDaleiass' � ��- SIZE. "SiORiESS�_'�.�.e.fAHRI]I 1 ADD NEL SAL H7 E)BO..-. . ..� .__i__ .__��.��.�•C A� .� . 37 0 . B ,,, . � . _� - ZHE.��NDEN GI�UP• E)-�.J-BE� �ESCRIPTIONOFWORK� 1� y------� NEW.-- � '-'�- 4 2, . ❑❑I om exempt onder Sec. -_ . _._.. _Gdx'd e_674.SF.-_—_-- -------.--.. _ _: - -- ,. .. .. . - ..��-.�- ALTER ❑ , I •3��.6 4,.,.' ... .. B.&P.C.(or this reason REPAIR . S___'__'_''. �.. . . , .. ' '_ . _ ._. . U '___ . __.. � -- oara: - use oF , • s 3 3 4 4 T . EXIS7ING BIDG. ��a ❑ .. . -. .._.__. ' - - --- rE�. _ 0&�2�f36__ : Signalurc � ._.... .. .' --''- -' " �' APPLICANT FINAL . OWNER-BUILDER DECIARATiON FR�NT'IS-IE AND.�i GROUP NO. ' . � - DATE..L-ZS� ..... ........ - - . . . --- --------- � -` . .. ._ . . __ .. _ .._.._._� -I here6y affirm that I am exempt from the Contractor's Litense � ��� AS dbOV2 Law fo�the foliowing reason'(Sedlon 7031.5,Business ond ADDRe55 FINAC" '- -' � '�"' ''•� ' ' fe:slons Code): . ._.__ ..._. .'- -" ' �- - paeSeNi '-By - - ' . - -�--- - - . . BUIIDING,- "�� ' ' . � � , � 1, os owner of the property, or my employees with ADDRESS�'� ���� r' "'` � 1 ^- ��`��•� ��••`� • �`��-'� ��,�a • ,. . � l-' woges as their eole compensation,will do the work and �� � ' � ' 'r. ---- ------ � � the stroctore is not infended o�offered for sole(Section ����TY' • '� '�"��� '• �'^ �. � ' �$• • •.�,• �,:.� ,� � . .-- -70E4;8osiness and Professions Code). -- � ---- �--- - MOwNG���� �-' -�"-� -'-'- ' "'-- -tEC.�- � ',--�' - -- �� -- ' '..__..___ _ _._ ..�; . '_ . . _. . � I,os owner of the property,am eKtlusively coMratling GOMRACTOR n10. . � •[1 8 9,�p, :,, . . with licensed contracrors ro mnstruct the project(Sac- - --- -- �-------- -....'--'-'---� -'---- -- -- -.. -..- � -'- -... -.- . - ' - -- .. . .. ._ . __.; � -- tion 7044,Business end Profensions Coda). ADDRESS ' -�.—�', t\. ; �' • ���,�.O O� ` _-.y..;�•�.lr •+, ;,`.'..�-..$'.: � -�- �CONSTRUCTION LENDING AGENCY ��---� -- �� SET BACK- -YAR� HWY- -- pR07.LINE WIDTH - � '�� � � -""t'-�-� � I __REOUIRED _ ___ _ -- - - --.�__;�. r. . -- I hereby affirm that there is a consvvtlion lending agency for FkONT :•- ' - �•� - ' r ..,, .. i -1he per/ormance of the work(or which this permit is iswed -- -- �P.l: ---- - -.. . ..._. _...._. __.__ - .--. . . .__._..._._ . _._ ' - '- .._ • o � 6 .,S � ..� � ; (Sec.3097,Civ.C.). SIDE . .� '.. , � . . .�. � , . -_' __ .... .. . P.L. . . . �'' ;� � • ..� . ' !'':�'•' Lender's Name�OTlt].I1221�e11. I�.1.11]O15 _ ' _ _ - '._ ' .' .'__ .-...__ < _. : . {......_ . �_ "...__._.� 231 S.-IaSalle,Chica IL :._ . '_:.334.69.. 4 �or,w a�r.x �• • _ ,, -. �-'- . . . . ...' , � - P.QFeeS � PermitPee-' 7H.rJ0_ . . � . '.:�.''. � . _ ... .._ lendei s Address ---� 693 . , ._, , I Certify thof 1 have reod this opplimtion and sta�e.�hot tha . -_ ....___. _ _ __ i:soeoce F��� �-0.5�__ . .�pqqp p��N _ ,_..__ _._ _ ____ - . ._ _. . . . _ .. _ .._._._ ,:. . abova informatio is tortect.I ogree to comply with all County inves��gaiion Fee ` �� ordinances an ota law5 relaling fo building conslruttion, -. To�ol Fee- - I _ "'' "� �•�' - -._ ...------ - - 489.00-�._...._ -LOMA Perm:k. ._.._. � . and hereb u orize represenla�ives of lhie County to enter �""---- '- "-"�' '--� � - upan th . ioned property fo�inspetlion p rpos s. __"__ ..""_' : __ '_...._.____ _ '_ ____ _ '_ _____._' __,._ __'_ ___ : . .._. . __ ' .. _.. -- -- �/� -- ----Idx�� � .$75 $35 ; SEE REVFRSE FOR EXPLANATORY LANGUAGE ; "_ _ Signafweo pplimntorAgenl-. _ _ ._ Defe_. "__ "__ __' "'_. '_' ""'_.......... _'_".'_"' '."'_ __-.'___•. _ .."_"'_'_'__. . ___._ i_.....,._". i""" ._' ' �i . . 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