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HomeMy WebLinkAbout1127A 1128A (5) . � .._.____ .. . _..___..__._ . _ _ , .,. .... . , _ _ -. ._ .. . _.._ ---- -•-----. ..__ ...._...._ ...__ ..- - - - ' WORKERS'�COMPENSATIONDECLARATION APPLICATIO-N� FOR �BUILDING��PERMIT�-� �-�-� I�hereby offirm,that I have o certificate�of consenl fo sel( , insure;or a certificate of Workers'Compensa�ion Insurance, - -�- -- - --. .. . .. . ..._ ... . or a certi(ied copy rhereof(Sec:3800,lob.C.)'� '' ' -- COUNTY OF LOS ANGELES BUILDING AND SAFETY ' 7�,�TC005-279=�p�� Polic o. n dt10i1W1Cl2 _ � BVILDING D :Cer�ified copy is hereby.(ornished.-� � • FOR APPLICANT TO FILL IN ADDRES$ 862 N. Featherwood Drive • �� Ceifified copy is flled'wifh th�e caunly building inspec- -�-"� BUitDiNG $62.r]. Feathexwood Drive � ; •tion departmenL� ' ' ' A�DRe55 ....:, . . . .. � ,,., ... .,' ,�. ,• "'._.. -_._ __.__. . . „ �• . . .: ' _'___. . ._ � .. .. . ..: Dote• Fi-1 q-RFi �Applicanl RwF,�. UnF'N.ARnitP arr- --Di�umrid Bar � � z,P .91765 ��,iin, Di�rtDrrl BaL' ' . CERTIFICATE OF EXEMIPTION FROM WORKERS'�� - '-'" -�- -- - ----NO.OF BLDGS.� �� � �--�---�- � NEAREST._. ._: .. � � �-� �- �� � � � �•�COMPENSATION�INSURANCE- SrzE OF LOT NOw ON LOT � CRO55 5T. Hl h KrioYi.&�Golden S �ri �'s' : � (This'ebttion need not be completed if fhe permit Is for one -- --- 3SZE1. ASSESSOR_., - ---�•- -� - �� = ; _ . . hond�ed dollors 5100)o�less.) TRAR BIOCK LO L Mpp gppl(� � • PAGE PARCFL . � . �" , �. ..�:� TE 1 tertif Ihat In the,performanta of tha work for whith this o`^'"ER-�-T� ANDEN-�F�UP � �No.�-967-9541 Z'NE �CIA`! I !� Y ( SPE �r 3 _ .. permit is Issued,�I shall not employ�any person in any monner . pD�RE55��P:�.Box 332 ---� �-�� �- � ��- -- ��� mn,o�nor,s r � ' � � so as to become sob'ect fa the Wo}k�ers'Co'rripeniolion Ldv+s. OfZVO S � r,o.4�45-4073 ' u .�TICE TO APPIICANT: If �., :�,.. ,;.�.�., . .: , ' ... . -_. .. . --- .._ . . ._..�- - . ., , , � _� � ..�. APPI'affer'making�Ihis Certihcala of . _ ENGHNEERT�vl� Ip T917 DIST�CT__ ����PE ; ZOREE_ _ PROCESSEDBY � ' � , Z �mp�lon,-you should become subject to"the Workeri NST'� J(q/ �/ -. a Compensation provisions of Ihe lobor Coda,you must forth ADORE55 't CdCl�3 1� 6 - �-- -��" �/' - - N wilh comply with s�ch provisions or,Ihis permil shall be .----- • TEL . STATISTICALCL4SSIF.IC(TION ' APt. CONDO: �Z � deemed revoked. ... ,..�,,..� .. ;,� ..,..�r..�'.� ,�.�..•�,=� CONTRACfOR � ANDEDI GF�UP No. --- i_ . ... _ - , ` - IICEN$ED CONTRACTORS DECLARATION•.r, �; � �-- � � -� - - --�-LIC. --- - Cl/•.55 NO. ��'��' �WEII.UNITS�� J I hereby offirm�hat i am licensed under provisions of Chapter 9 nDDRE55 FLS a1�OV2 r,o.371580 , , (tommencing with Section 7000)oi Division 3 of rhe Business and _ _ _��� B __ _ � ��R�� � � , ': �. � -� 5°EF`].446 s oa°S - fnl�nlL�iES �' CONE - - ' - AUDATION i ��censeNumber 371580 I.�c CIOSS B _ DESCRIPTIONOF WORK � ZE �iRl1]. - NEW._ VAIUATION _ ,.__ ' . •�'p Professions Code,and m license is m�full force and effect. Cltt M55 CvMroctor 7.�+�AP7D�1�GFd�JPDate 6-19�86 ; �• • •'•2�1 -� � 54,000 . � � � '� ❑I am exempr under Sec. , GdL'3CJ0.47Q SF `ppR � S , � ... -� •2;�-�.� (� . - -. .... .._ ------ --- .. .,.• ... ... ❑ ; 8.8P.C.forthisreason . . REPAIR ❑ . ;. _. .. . �- - - -. - ---..• o-CJ-1,1�6 � . .. ._ _ _ .. . ___ _.__.'_"__Oale:".' ' ' USEOF DEMOL ❑ � ' �- ��-----0_£�22"�,6._..' , ._.._. ExisnNc eioc. ----Signatvre �..__..... .. -- - - - - neaiCnNt r�.� �� Ci�P TEL FINAL�O`� y�� '�, i , , OWNER-BUILDER DECIARATION PRIM N�• _. DATE � , ----'- -. ... ...- - .... ._ ..-- - --- �----. . .._. . _. . . -_ , .1 hareby affirm that I am exempt from the Controctor's License j�$ �]7pVe ,. . ' ,,� , ,.� ' ' ' w for the following reason(Section 7031.5,Business and ADDRE55 FINAL ..,.;..; ..__........ � t�q . �fessfonsCode�:_..._ ..,. .__ .._._. . . .._ Pe N BY_ .-- . . - - .. __ _ . _._ . � . .. I BUIIDING %•� � L.V f1 I, as owner of the property, or my employees wifh ADORESS � w6ges as th�eir sole compensatiori,-will do the work and � -� '� �_ � � �r o 0 o a e � fhe strucNra is not intended or offered for sale(Settion ��°'��tt '.•'`•'.^' �.` -'-' �', ' •• � - - � � -----7044,Business end Professions Code). � - �-' - -� MOwnIG � - � --- �1TEl• � ��. `�" , � �� � ��� -� �- '' � � •J 3 Q�Q� ' �J I,as owner o!the propeAy,am eaclusively controUing COMRACTOR NO. � . - - -__- -._. . .-' -. - - . "'__ -_._ _� .... ..- with licensed coMractors�lo tonsfrucl ihe project(Sec- -'-�'�- AD�RE55 � ^ � . ti, ' °^'J J�7.G'�� - ' tion 7044,Business and Professions Code). • t�� ' ';,'"Vi'.�: REOUIFED TOTAL SEIBACK FROM _ XI I. __ _.._ .._._._._-_._. : ��.= -"�- --"�- "CONSTRUCTION LENDING AGENCY--""""- " --- Sei BnCK YARD HWY� pROP.LINE WIDTH O Fa P.Z�"�6 ' - I here6y affirm thaf there is a tonsiruction lending agency for FRONT !'!i ' �'•���."j� i ' ' ' � -tha performance of the work(or whkh�his permi�is issued -- �- -a1:�----� --- - -- -.. ...._.. ..: _ ...'- -�-----. .... `-' -'- '.._.."---" -.:-- }- . (Sec.3097,Civ.C.). SIDE ~ ��� 'K�1�-;_•( � . . , ' . ° - --..._ Continental Illirnis ---- - -- r.�. � —-_... - ' • �'.�- -- --- -- - . . , �•. •.. .�. ,;�-i • i i % lender's Name , ' (pMq Ref.M "�� �� ' � � a _231 S..IaSalle,.Chicago, IL.._. p,C.Fea S 23I.16 - - onm„�e� 325.50--- . � - -� --- . .. ' . = lender•s,4ddress 93 ' , ; � � • . : . _.,,, 9 .J certify that.l have read ihis applimtion and.slote.that.the ____ __--_ ._._- . _. _ _ Iss�anceFee- ._ lO.SO - - : -LDMA P/Ck..... . ... . . .. ... . ... . . ..f. � obove informotion' rrecf.�ag�ee ro wmp�y with oll Couny i,,,,e:n m�on Fee '� � � ' � ordinonces and a Iaws relating to building tomtroction, .._.._ . . _ Torol Fee- --�- -33E7.��--�- ' LDMA Pnm.k--- - �-- � � ---- - . . ._..'_ .__9'_.._ . ... _. _..._. .._' ____._- . i and hereby h represen�atives of this County to emer � � � � opon th a v enr d property for fnspection porposes. . I � ' 3 -'.' - . . -- -..... . - --.- _._-- -- _ '.� . - . - _ ._ --'.'-- . ..._ .....--- ._..--.-"-' '- . --"-. ., - -___' _' � . � - - SEf REVERSE FOR EXPLANATORY IANGUAGE � , , - �--Sig.w�ureotApplicontorAgeN .'_ _.... - .._ __ '_....' . __' ... . _ _._ .._ . __._ ......... . _ . . .. . . _.. _. _..._ _. .__ '. __._. 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