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HomeMy WebLinkAbout1407A 1408A � . WORKERS'COMPENSATION DECLARATION � . .. ' �� ' � ,Q 1'- ZS il Fereby oifirm Ihat I have a certifitote af�o�=e�;,o 5e�t � . APPLICATION F�R BUILDING PERMIT � insu�e,wr a certiiitafe of Workers'Compenslion Insurance,or a certifted copy ihereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES . BUILDING AND SAPETY �c,�,5-101-391 Company ���t � : - Cerliiied co u hereb (urnished. BLItDING ❑' pY Y FOR APPL�CANi TO FILL IN ADDRE55 �} Cert�iied copy is filed wifh the couniy building inspec• BUIIDING en 18[1 }ion deparlment. ' ADDRESS ,lV� CiQ].C�PTl S ]}r :�Jpr'{j� LOCALITV Dlc'�I10L1C1 B3T oo�e 7-1�t-81 APP�;ca„� ZHEE ANDIIV (120Up CITY .. D�-�1d S3Y ZIP 91765 ceosssr. SLIl1Set GYOSSixlg . CERTIFICATE OF EXEMPTION FROM WOttKERS' ` NO OF BioGS. a55ESSOR � � � � COMPENSATION INSURANCE � SIZE OF lOT TR. �31274 �NOW ON LpT MAP BOOK GAGE PARCEL (This seUion need not be mmple�ed if the permit is for one : u5 qNe nnnv TRACT :• ' BIOCK �oT�LDG. 33 } � hundred dollars($100)or less.) � . . � NO. ��.3' 3 �� ' iEt. ��y-p SPECIAL a �1 certify Ihot in Ihe performance of tha work for which ihiz oWNER� ANDIN C�OIIP � No.599-6864 � u CONDITIONS � O permi�is issued,I shoil not employ ony person in ony monner ,.00REs629 Cavina Blvd� DISTRICT GROUP iYPE FIRE PROCESSED BY V so as io become subject to the Workers'Compensalion laws. � . � CONSt.� IO� a arv ' ziP �� '�'/ � /✓ a�e.,et/ O Da�e � Applicont ARCNITECT OR T � SIAIISIICAI C1A5,5r1F�ICALl10N � �� APT. CON.Dp/, . V NOTIGE TO APpLICANT: If, aife�moking 1hi5 Certi(icole of � ENGMFER I�brano & Pauli 21 �347-6555 C7AS5 NO.�DWEIL.UNITS T`l (� ti Exemption,�you shouid become subjetl �o the Workers' y �Compenso�ion provisions of the Labor Code,yeu musr forth- a0DaE55 �4766 PaT�C� T�ffi1fl�d� L'3�-�8S2S 5.\YER 7'AP with comply with such provisions or this permif sholl be TEt. — deemed'�evoked. CONTRACTOR�+ A�IN Q��� No.599-6864 BK. PG, � VAIIDATION LICENSEO CONTRACTORS DEGLARATION � � LiC. . I hereby oHirm thot I om licensed under provisions of Chop�er 9 . . A��RE55 -- �NO.371 VAIUATION � (commencing with Seclion 7000)oi Division 3 of Ihe Business and ���, 2.) 4 Q.�.A Professions Code,ond my licenze is in Full force and effect. Citr " Ctn55B 5���Q��.O� - � � . u�e�,e N�mbe. 371580 ���.c�os, B ". s°e`T 5241 5 oR°5 2 F MILOIES 4 o EK � #.• • • •2,1 co�va�+o. � � ��pore �a�� DES�RIPTION OF WORK NEW g] S /�/� G�� `I •4 2`a 0 4 ' 1 � I am exempt from the licensing requiremenls as I am o � �-pl� C�� � � A�� � • •�2�Q Q= � U licensed orchirect or o regisiered professional engineer ntiee, � 'FINAL / � acting in my professionol capacity (Section 7051, ' REPAiR � DATE 50 �y �o, Q 2�� _$2 � � Business and Professions Code). U5E OF � FINAL ' EXISTING BLDG. � OEMOL BY LiC,or Reg.NO. DofC APPIICANi TEL. � � ' ' � OWNER-BWLDER�ECIARATION - - �(PRiNT���� �IN �QU� � � N0.599'6864 . // � !l I hereby aifirm that I am exempt from rhe CoMroctor's License A�DRE55 629 Covina Blvcl. S8T1 D]IilaS '� - Law for 1he following reosan�Section 7031.5, Business ond �1 4 Q 8 A � PfOfeSSiOnS COd@):. FRESENi � - - ❑ - BURDING . . � . � , � I, as owner of the properfy, or my employees wilh�� ADDRESS �• • • • • wages os their sole compensa�ion,will do ihe work and .. � -�he s�rucfure is not imended or offered for sale(Settian�- ��A��TY �� - � � � '�' -I •7 6 7.5 0 7044,Bosiness ond Professions Code). " MOVING TE�_ - � • . � � �I;as owner o1 the property,om ezdusively conVacting CONTRACTOR NO. . , •.�'��7,Jr O� with licensed canlraclors to construct ihe'projecl(Sec- qpDRE55 .. , O 2 O� �8 2 � -- � tion 7044,Business and Pro�essions Code. REOUIRED TOTAL SETBACK F20M EXIST. CONSTRUCTION LENDING AGENCY se7 BnCK YARD HWY GROP.IINE WIDTH ` � - I here�by aifirm thot there is a conslruction lending agency for FHONf '- �• � - ihe performance of the work(or whith this permil is issoed p�. , � . � (Sec.3097.Civ.C.). � SiDE - .. . � ' � . . Ccntinental I1linois P` ' �L3�.e�$.�La e O uwi.s ,/ � � P.C.Fee S S U T Permit Fee S �O� � lendei s Address • �� ' . � - . � � I certify�ha�I have read ihis appiicotion and s�o�e Ihot the Issuonce Fee ..��0 _above in(ormation is correcl.1 ogree lo tomply wilh oll County_ . investi9ai�on Fee . �1 ordinantes and State lows relating 10 building constroction, To�ol Fee ��/•-��� and hereby thorize represenrmives of this Cauniy to enier ' upon Ihe ve-menfioned �operty far inspetlion pmposes.'}^' , , � � - -�� l��-` �� � -SEE BEVERSE POR EXPLANATORY LANGUAGE � ' � Signolure of Appliront. g .. pole , ' � � ' . .. .. . . . .. . , ' ...... _ . . . ._._ . _ . . . . i ... _, . . . � � _. . ..-. ' � � a o � T � { . ' � � .W O . T,� � � � � �° '° .o m- 7�m = o. o S n. '� . 0 0 � ' -n � x � �^O�� �^ n. � p '�O :," � � N N O . � . Q T O t0 t� -.- �: .p P D O . �- m p c O 10 D% '"'j . (�7 � 3 O e o r. O'4 7 j Q� S � tA � . .�: Q^�7 .bqp '. �� �m�c9 r O'O ± '� N . 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