HomeMy WebLinkAbout1407A 1408A � . WORKERS'COMPENSATION DECLARATION � . .. ' �� ' � ,Q 1'-
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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 , ' � � '
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