HomeMy WebLinkAbout1409A 1410A I WORKERS'COMPENSATION DECIARATION . � � �
, I hereby oFFirm that I have o certificate of tonsent to self.
� . ,�,��e„o�a certificme of Workers'Compenstion Insurance,o, � - A P P L I CAT I O N F�R B U I L D I N G P E RM I T
a certified mp thereof(Sea 3800,tab.C.� COUNTY OF LOS ANGELES- BUILDING AND SAFETY
p���-1�1=391 Company �£0[1311t � - -
Certified copy is hereby furnished. � - BURDiNG )rl� .�+O1�I'L S �•.
❑ FOR APPLICANT TO FILL IN ADDRESS P�PrS (NOrth)
� CertiFied[opy is iiled with the tounty building inspec- � BUILDING
� fion deportmenl. � � � ADDRESS 510 Golden Springs Drive �North) i�i�T� DiaIIlotld B�
Dote �-ll+^81 Applicant � �IN �� arr DiffiI1ond Bdr ZiP 91765 c"Rossssr. S�set Cross' �
� �CERTIFICATE OF EXEMPTION fROM WORKERS' " � NO.OF BiDGS. ASSESSOrt . �
� COMPENSATION INSURANCE � �� � T NOW ON lOT MAP BOOK PAGE PARCEL �
(This seciion need nor be campieted if tha permit is for one - u5E ZOrvE n/wv ,/LJ
hondred dollors�5700)or less.) - TRACT �.-_ -- BLOCK lOT N�I+�• 34 ,f,''j NO. �x 3^ .3'�'" / � }
. . TEL. ��Bt'T� SPECIAL , a
OWNER � ANDEI�II (�tOtTP No.599-6864 �ac. COND1110NS�
�I ceriify fhot in the performance af the work for which ihis � �
permit is issued,I shell noi employ any pereon in any monner 6'Z(� COV7Ila B1V�. DiSTRiCT GROUP TYPE ,FIRE PROCESSED BY �J
ADDRESS ' CONST.J ZONE
so as to become subjecf to the Workers'Compensatian Laws. � � 2
arr San Dim�s z�P 91773 /o �C/ � � �a1�.v o
Dale � �Applicont � S1AT4TICALClA551FI�ATION -APT. CONDp. V
NOTICE TO APPLICANT: IF, after making this Certificote of ' ARCHiTECT OR T _ - / �L
�Exem plion, yo� 5hould become su6 ject to 1he W orkers' ENGINEER Mor�o & Pauli �2�3 347-6555 CL4.SSN0. 1�` DWELL.UNITS t O.
Compensolion provisions of the Lobor Code,you must for�h•-- qD��E554766 Park Gr�ada Ci312�J2S2S �
with comply i�h such provisions or this�permit shall be � SCWERMAP �
deemedrevoked.. � CONTRACTOR Z�' �'� �P Np.S99�EHE�F BK. PG, '�- VALIDATIDN
- � �LICENSED CONTRACTOR$DECLARATION � - ��� '
I herehy aifirm thot I am licensed under provisions of Chopter 9 . ADDRE55 . N0.37�� VAIUATION � '
(commencing wilh Sectio Y7000)of Division 3 04 the Business and , . � � CLA9Y " " � 5 c7-� ���,00 , ��.4 a 9.A ,
Pro(essions Code,and m litense is in full(orce and e(lecL CITY � � � ���-�� -�� �� � - � �� �
SO.FT. NO.OF NO.OF CHECK ' "#���.• •'��� ,
License Number 37�� u�.cia:: B size 5241 STORIES Z fAMI�lES 4 ONE
NEW � 5 •
Conlroctor �� �� ��poie ��� �ESCRI7TION OF WORK � 4 2 S 0 4 ;
� 1 am exempt from the licensing requirements os I am o �hP1PX CCH1�0 A�� � � •4 2 5 0 4 c=.� '
licensed archi�ect or a regis�ered professional engineer,. _ _ . _ , . . _ _ nLiER Q FINAL
actin in m roiessionol ca acit REGAIR DATE �
g y p p y (Seciian 7051, � � �2 ci�- �2�� -8 2
Business and Professions Code�. _ ' USE OF � DEMOL ❑ F�NA� ` '
� . � - E%ISTING BLDG. B .
Lic.or Reg.No. � Da�e APPLICANT 7El Y ' . ,
� � � OWNER-BUILDER DECLARATION " " IVRiNT� �� L�IN QZO� No.599-6864 _ �
" I hereby affirm that I am ezempl from ihe Contractor's License AD�RESS6�L9 COV1Ild Bl�. Sffi'1 D71]19.S CA � �1 4 1.Q A
Law for�he following.eoson(Seciion 7031.5, Bus�ness ond . . � � �
Professions Code): - pRESENi . � #. ��.. , . �
� I, as owner of the properfy, or my empioyees wilh � ADDRE55 � � , �
' wages as their sole compensation,will do ihe work ond � . � '_ , . . �I.•�7 6�,Jr,�
� - the strucNie is not iniended or oifered for sale(Sec�ion�-' tOfALiiv - — - � � � �
. 7044,BuS�ness ond ProfeSsions Code). � MOVING TEL. � • ��•7 6 Z 5 0=
V
� I,os owner of the property,om ezdusively contraciing � ��NTanCTOR NO. . . .. . . �
with licensed contractors to conslrvU the projetl(Seo- qDDRE55 , � . �Z Q� -8 2
_. . .tion 7044,Business ond Professions Code). � � � � - - -
REQUIRfD TOTAL SETBACK FROM EXIST.
� CONSTRUCTION LENDING AGENCY SE7 BACK YARD HWY PROP.UNE WiDTH � � � � . '
I hereby offirm thal there is a constroction lending agency for -� FeONt ' ' - � � '-
the performance of the work for which�his permit is issued p� . . , . '
. (Sec.3097.Civ.C.). . � . � . . _.. SiDE .. . . . . � � -
CAC1tll12T1t31 ILZ1T10LS r�.
Lender's Name / . � � � � �
� 23�. .S. I+a a e, CdgO� 1I1015 p,C.Fee S 7.l/� Permit Fee C�OV
Lende�'s Address �
I certify Ihol I have read this applicatian and slole ihat the Issu ce Fee �j D
. above iniormation is correct.I agree to compiy with all County ���esngafion Fee . �� � � i�) . ' �
ordinances and State laws relating to boilding conshuUion, � Tmal Fee � 3✓ � � -
ond hereby thorize representaiives of Ihis Coun�y io enter � . '
upon Ih ve-menY n properly for inspetlion porpbses. � . . . � � , � �
�ifC� � �j�� SFE RFVERSE FOR EXPLANA70RY LANGUAGE � ' � � � '
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