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HomeMy WebLinkAbout1101A 1102A ,.... . . . . .. - ---------�---- -- -- -. _.... - ------__�. . . . __ WORKERS'COMPENSATION�DECLARATION � • T � �� ��� � ��� � i . ...,'' .__.". . .� "';:',� ... . . ", I here6y afFirm that I have a certificote of�conien�to self � � _ _ insuie;ora�ertificate of Workers'�omPe�Sa,�o���=�,a��e, --APPLICA�TI4�N�-FOR-�-BUIL�DING� PERMIT � ��� ; .. ------ - -- - or a ceitified copy Ihereof(Sec.'3800,lob.C.), ..:.-. - � " _____.._. ._ .._ .. . ' Poliryf��WCOOS-279LO�pa�y� Nati..oraaide� _. _ � p COUNTY OF LOS ANGEIES _ BUILDING-AND SAFETY - � . � ,.Certiiied co ii hereb furnished.� BUILDING ' � PY Y ✓ FOR APPLICANT TO FILL IN aooREu 868 N. Featherr,�DOd DriVO ���Cer1i(ied copy ii(iled�with the covnty building�inspec• -'"`- gUIIDING . , ' tion departmeM.'�i� '� ADDRE55 868 N. Feather�,pod Drive . . ,. ��. 1,.�. „ ,;. .�.�.,, . .,,,',' . ,,.� .... ._. ..--- ._ .__ . , _ . _ .._... � Dole��(-1�l-RF�'� Applicant�;�AN1�F:N•(�RnT1P CITV ZiP � --� LOCALITY . �� �� CERTIFICATE OF EXEMPTION FROM WORKERS'' � -- NO.OF BtDGS. -----�----- NFAREST.xl h-Kmb�.& Golden�S � ' � �` + " '� COMPENSATION�INSURANCE• � � -•�� SIZE OF LOT NOW ON LOT CROSS ST. g �'lI1CJS �'�-"�` ; : (This sehion need not be mmpleted if the'permit isfor one -��-� � � ---- -- �-- --- - -- --- - -- : ASSESSOR.,. �--� �- -- � �.. � � hondred dallors(5100)or less.) , , . , TRACT BLOCK LOi NO. � /f,qp gppK � � PAGE� PARCEI ' I Certi( ihal . TEL. .... U O fE �P . ... , . -.� .. . .. . . __ . __ 555ccc��Z , y in the performance o(the work for whicB�Ihis ONrtJER� - NO." - � ,,�. � /z 3_3� �� ,, . ..; .... permil is issued,I sholl nol emplo'yony persan in any monner �p,�.�.ox.3329. � �a� . soean�. - -- - --�- - -- a. so os ta become subjed lo the Workers'Compensotibn Laws. A�R � � - ��--" � � CON�RIONS � ' � 0 ;::,�.._ . ..,�,._ . ... . ., . � - . .,. , E55� - . _�., . � ,U . .. . . . ., ,.. . � l, .,, � :. ..;,.. � . , „.. arr. . CAvil'�a_..,__ .... _ ._zir..91722__.. .__.. ---- - --__. . -- , . _.. _ ... ..... . - - - � e .,� . .APPlicanr � . � . . -. . ARCHITECT OR TEL. �� `TICE TO APPUCANTi'If, ofter'mdkiri this Certi(ica�e af DiSTR�CT GROUP TVPE �FIRE PkOCE55ED BY... � /� 9 ENGINEER NO. �xemption;�you�should become's�bjecf^to'Ihe�Workers' -- - �� �W ' Compensafion provisions of the Lobor Code,yoo musl forth- qDDRE55�314 N. F']L'St� Arcadia _._/_� _v'�,3 �� � � ��a wilh�comply wilh such�provisions or this�permit.sholl be -� � � �� �� � � ��- -��'-� �--� - "-�� ' deemed revoked.-,� �,,, ���� �.,, � ,.. , . , TE� �� STATISTICAL CV+SSIFICATION A7T. CON�O.�-� ��Z CONTRACTOR ZIiF. P,NDELd GI�DiIP NO. .�' — � LICENSED CONTRACTORS DECLARATION �•��� �� - �--- � - -- - -� - .-���. . -_ ._._..__. �-CL4$5 NO. � ���04VELL UNiTS� � � � ��� � � ! � I heieby offirm that I am.licensed�nder provisions of Chapter 9 ADDRFSS No. (commencing witb Section 7000)of Division 3 of the 6asiness and . __ ��� SEwER rowv • . �� . � . • � �Professioni Code,and my licensa is in.full(orce and effeU. Cltt C1q55 - - - . -- - ---� -- - � • .,.... . . . . . .,-.... . $ BK. PG. ''�� --VALIOATION " �,, ' � ' �� $Q.FT. NO.OF NO.OF CHECK_ ' ., . ,- .•..`... . `B� . •..�� .. . SIZE -��.7HGSTORIES��- -�- - FAMILIES-1 ONE ' ;�. . ,. ' .,,-. � ... . : LicenseNumber 37�-SHQ�'� •'lic.Class VALUATION � � � co�r�aua��IE ANDEN GFY�UP Data 6-�.9"HS "_' DESCRIPTIONOF WORK_ - • .. ._ NEW- � S . GS,320 ';----i ► - . 1 1 Q 1-A - ❑i em e.emP,��de.se�. -�----.Garage..445.SF Aoo p _. _ . --. . _ -- --- - - - - - . . , . . . -, � .. _. . . , ALTER � ', + �e • • •�� , . B.BP.C.forihisreazon __._. � -S-' -�---.--....1_. ...; _. . ,. '--.- -- .' � REPAIR_ . .__ -__ __ _' - '='Date:_'_' EXIST�ING BLDG. DEMIX ❑ I •��J H I]S ' , 1 hereb atfirm�hat I am e.em 1 from the CoNractor's Licensa `�.-� AP�PR MT��� GROUP ..---Np... ... .---- -"DAT&.'Z� .G&.[�¢.8�..._, ,.�. Signafure "-' FINAL ' J� OWNER-BUILDER DECLARATION � _ � 2 _ .._.. _.... _. y P AD�RE55 � " ' '�w for the tollowing reason(Section 7031.5,Business and FINAF '� � " "� -� � �� ' fesslons Code):' '.' '----` �-....... . .. _ .--. vttESEM . Sy-.. .. . - - -- - --� . BUII�ING . .. '.. .. . . � I, as owner of Ihe property, or my employees with ADDRE55 ; ! �: �� - ' � ._.. wages os their sole comperisolion,wili do the work and � , ��' �' ""�"' �"�- "" " --- -- ' "- - � the srructure is not imended or offered for sala(Section ����TM ' � E� � O,2 A � ' . _-7044,-9osinessandProfesslonsCode). . . .. ' ' -- - MOVING_ .. . ..- --._ .__-. .. . TEL. . . .....� .. _.._. .---- -. -=- -. . -- '--- ---- -- __ -- . CONTRA[TOR NO. � I,os owner af the praperty,am ezdusively coniracting � , .i. . � � �� � -with licensed contractars ta construct rhe pro�ed-(Sec- '-- ... . . -' -----------�-----.--. - . ... ...'--- � � - �' - ----- �-- - -'----. ..- --� --- '. . ... lion 7044,B�siness and Professions Code). ADDRE55 � � _' : ' r •�., `".f'.. i i..I �J A Q ._.._._. .._ _._ REQUIRED _ TOTAlSEiBAIX M %I . _ .._ ._...__ _• . . �'�� .,-._I�., _.. .. . _ �O ,�"" �CONSTRUCf10N LENDING AGENCY-" SET BACK YARD �HWY pRpp,�WE WIDTH � ' i hereby aFfirm that there is a construction lending ogency for FRONT . � ' � °•:)�Q��c=i�'� � �., .,.....:'�. -the pertormonce of�he work for which ihis pe.mit is issoed �- �- �a.L. . .... ..- - - --- --'- --- -- --_ . .,. . . .---'._ .. _. . ".Y..;_.`.-:' ...' �' ._ . (Sec.3097.Civ.C.�. SIDE � � ^ . O II.2�"'8O � , , , � __'__ — _ ' CAl1f3.11elltd�. I�.�.11Y�1S P.L. - _ � ,,. ' "- _'_'... ._ _ -------- - - , ; Lender'sNome , I.--�� P.0 Fee E 2 � - P��m��F�� --379.50 �DMA Ref.M � . ��.. ; '� �� ' ` � . ; ------ --- -- 231 S. LaSa1le:Chicacro; ' �-;. ' lender's Address �+ �� � " - ' '� � � ' i. , ' .I certify.lhal I have reod this app�imtion and slote Ihal t1�OGJ3 _.. .___..- _ Iss�wnce Fee �--- � �'�.50._: mr.an vic a-.------.-. - ,. _' _. '. �' '.•1' � i � obove informati is cortect.I o ree to com I wilh oll Coon ' �� � ' ; 9 P Y �Y Invesri o��on Fea , • ' ordinontes ate laws reloNng to building construttion, 9 390.�� ' �����' � I .. __.._ _'-__........__...__ .___... Tohl Fee._. _...__ ..' .IDAM Perm.q.._.._"" _.... ._._ __ ,-- ..__ ' � and here a orize represematives of�his County to enter . --� � , ; opon th o o- �loned property ior inspeUion urposes. LDMA - ' $7S ' � � ' � ...._ .. - - -- .. . . _ _ GG ... . _"-' - --- --- - � ; � -- ----. " '- . -- -- ._ . . . ... .._ _ . , Q O SEE REYERSE FOR EXPLANATORY LANGUAGE I -.- ._Signarureo ApplicanlorAgen�.'.. -._. �e__ --. ._,___ . __ ._ -_'_- ._ ._ ' ..__ __ .__'_ ..�_.___ ____' __ .. .. . . i.._ _ . - '_ '_ _ . C7i I r r�� - �'^s"'. , ' ' ' y��.,,.r�" � .. - ,y ^�...r`�"�� _ , - Q (O_ .....�'� .. ' � . • ' ...Y^".r�^� .n _w. . . � ' ,T 'r G' '�,t.� n �. C ..�'� . . � � .� �.O . y�w...... �,�_ t�� O �,N , r,,,,,,"..,++ �, �a O t a. O ? n ' �„'....-.. . • v o n� �'o o � fD � '� 'D O - ...r^'�r� . . • , O j n, J� �O,' � O 9 �1;�, 9' � . �.�.,,,.,.� . . . ' . . � � � � p O O� � � �.n 'p��� ., W � ..i " �"�`-���r f'+ T O C a O i0 O ?�''"O: j'� � m � M��'� . . r� r � o d � p 9 � p � . oo � �• 7► Tn= � ` � � Q �; 4 �, ^; J,n � . N � . , �'p o.� N � ��? � � ,�' Q -f�� � ', � , Z O a ; ^� x ^f G � a a' � � .. _ - ° , y o W? � ° o o n- � �. . 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