HomeMy WebLinkAbout1413A 1414A (11) `!
WORKERS'COMPENSATION DECLARATION . . - -�
I hereby affirm Ihot I have a certificate oF�o�,e�„o seif qpp��CATION FOR BUILDING PERMIT
� �insure,or a certificate of Workers'Compenstion I'nsurance,or �
� ert fed c p rhe� oi(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
o�cy�5-��1-3�31 Compony ��Llt . . . _
� Certified topy is hereby furnished. fOR APPLICANT TO FILL IN BURDING
Cer1ified copy is filed wilh ihe tounty b�ildin ADDRE55 52� �i01�11 S r1�S �Y��NOr�'1�
� ti0n departmenl. � , . 9�nspe[- ADDRE55 520 Golden Springs Drive(�z+� �p�ALIN 1}18IIbT1d B3r -
7�1L�_81 '� ��.� �0�, NEAREST
Date Applitont � �iTV-�- D13�L1C� B$L' � Zip 91765 ceosssT. Sunset Cross'
• " 'CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. n5SE550R
' ' COMPENSATION INSUkANCE SiZE OF t0T NOW ON tOT MAP BOOK vnGE ' PARCEL
• (This setlion need not be compiEted i(ihe permit is for one � � � USE ZONE nnav q
hundred dollars 5100 or Ieis. . , TRA[T . 6lpCK LOT NC$�(' 31 / � }
( ) ) �*m�.�,` �m ,�'� No. /1.3-3�f
OWNER IIIE t1LYlJLJY C�OVr TEL. �-�-� SPECIAL
I terlify ihal in ihe perfarmance of ihe wo�k for which this No.599-6864 � (� fONDITIONS �� �
permit is iss�ed,I shall nat employ ony person in any manner . oiSTRICT GROUh TYPE FIRE PROCESSED BY V
so as to become s�bjecl to)he Workers'Compensation Laws. ADDRE55 629 Covina Blvd CONSy� ZOyE Q,
��TY s� D� ��P 91773 '° �� �= � ,d��-� o
DOte Applifonf - STATISiICALCLA551F1 ATION APT. CON�O. ~
'NOTICE TO APPUCANT: If, olter making this Cerliiicate of � ARCHITECTO r V
Exerription, yav shoold become subje[f to the wa�ke�5 ENc�NEER� 1`'brano & Pauli �21�`./347-6555 CLA55 NO. � DWELL.UNITS�� � y
Compensotion provisians of�he Lobor Code,you must forlh• � y
ADDRESS�F766 P2TIC Grffi1$C�3 Ci�db2Sd$ SEwERMAP Z
with compiy with s�ch provisions or this permit shall be TEI. —
deemed revoked. . CONTrtncToe`j�� � (�� No.599-6864 BK. PG, VAl10ATION
LICENSED CONTRACTORS DECLARATION �i� ,
I hereby afiirm thof I om litensed under provisions of Chapter 9 . . ADDRE55 .NO.37�.S8O VALl1AT10N '
(commencing wi�h Sec�ion 7000)of Division 3 of ihe Business and tiC.
, Prolessions Code,and my license�s�n iull force ond effecr. . aTv �. . .. .- c�Ass� -�� .E36$�000.Q� _ .. � � 'A� 4��;3 A � � � � � �
Ucense Num6er '37�"5� L'IC.C�OSS B s°�e`T� 8955 5 oR°Fs Z F MILOIES � O EK �
- TTp �7.� ��• • • •'Z.'� �
ConnaCtor �� A�IN ��"'pota �1�/ OESGRIPiION Of WORK NEW � s � �
❑ •
I am exemp�from the Iicansing req�iremenis as I am a/�� 7�P�-PX COLldO �`�� ❑ � 7� 7,3 6-
� Ileemed erchirecr or a regis�erad profev(onal engineer __. , niTErt � FINAL // � , •'•7 1-7,3�6=
otfing in my professional mpacity (Seclion 7051, � � � � � � - � DAiE Y� �� �� - " �
B�siness and Professians Code). REPAIR 0 2�� -8 2
USE OF FINAL�
' - � � E%ISTING BIDG. � � DEMOL ❑ B
�iC.OfR�g.N0. Dal� APP(I�R Ti � �IN.��p . No.599-6864 Y „ . .
' � OWNER-BUIIDER DECLARATION
I hereby aifirm ihar 1 am exempt from rhe Contracror'e License qDoae55 629 Covina Blvd S�1 D]Sik95 � �
law for fhe iollowing reazon(Section 7031.5,B�siness and , f � �� �
Proiess�ons Code):, aeservr ' �1 4 1.4 A
--❑ � - - . . BURDING __ . . . _ . _
I, os owner of 1he property, or my employees with ADORESS �#� � � � �',
wages oe their sole compenso�ion,will do�he work and � ' .
� ��he srrutture is not intended or ofFered for sale(Seciion � ' �aA��TY ' ' "� ��2 8 9�5�
7044,Bo5ine54 ond Professipns COde). ' MOVING - TEL. �
� I,os owner of the property,om exclusively conlraning � GONTRACTOR NO. ' • 1,2 8 9,�5 0 u
with licensed contractors to conshuct the projetl(Seo qDDRE55 �
� � � �ion 7044,Bosiness and Professions Code). - - � �� � O�L O� ''8 P
REOUIRED TOTAL SETBACK FROM E%IST.
CONS?RUCTION LENDING AGENCY -SET BACK' �ARD HWV 7R07,IINE WIDTH -
-I hereby aifirm thot Ihere is a mnstruclion lending ogen[y for FkOnll � - - ��
ihe performonce of the work for whith this permit is issued p.�, ' .-
(Sec.3097,Civ.C.). �� SiDE - -� � - . . . . .
Continental Illinois P`
Lenderi Name . � � � �
231 S. La Salle, Chieago Illinois p,C.Fee S / Perml Fee ,2�/, u e�
tendei s Address �
I certify thot 1 hove reod this application and sta�e thoi ihe issuonca Fee P•SO �
above information is correct.I ogree io comply with all Coumy . n,�esegauon Fee . � . . � � '
ordinances and Slote lows reloting�o building construction, To�ol Fee ��2..Q9 .f(J � �
and hereb authorize represenia�ives ot this County to enter . .
� upon t bave-men iv ed properry fo inspec�ion purposes� � ' � � � �
C(/<+/ j�� '°'�`f�l �j� -- SEE PEVERSE FOR EXPLANATORY LANGUAGE / � � � �
, S�qnoNre o�Applic �o� ge�l Da�e ' � . �
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