HomeMy WebLinkAbout1417A 1418A (11) WORKERS'COMPENSATION DECLARATION . . . � � �
I.hereby affirm that I have a certificate of�o�=e�,�o,e�{. . qpp��CATION FOR BUILDING PERMIT
�nsure,or a certificate of Wo�kers'Compenstion Insurance,or
a ce�tifiC�d copy thereo((Sec.3800,tab.C.) . COUNTY OF LOS ANGELES BUILDING AND SAFETY
���5-101-391 Compony �Q017a11t �
Certiiied co is hereb furnished. BUiLDiNG
av v FOR APPIICANT TO FILL IN ADDRESS 530 Golden S s Dr. North
f] Certified copy is filed wiih the county bvtlding inspet- BURDiNG .
�CXI tion deparfinenf.' � � ADDRE55 - S3O GOZ�LI S ]Jrive North IO�ALITY� Dlc"lI[YR1CI�B3T
�oaie 7-14-81 APPi;�o,,,� ArIDIN C�UP - oT� Di�Zd Bar. z�P 91765 ceossssr.
CERTIFICATE OF EXEMPTION FROM WORKERS' � SiZE OF LOT � �u31274 NOW ON IOTs AMP BOOK ' PAGE PARCEL
- � COMPENSATION INSURANCE � � �
(This seclion need nol be wmplefed if Ihe permit is for one _ �� u5E zONE �P ��_j,r�G, '
hundred dollars(SI00)or Ie55.J , TRACi - - BLOCK ior r$T.D(' 32 ,�j . No. / y
. TEL. -f—l� 57ECIAl . p„
. 1 certify ihat in the�performance of Ihe work ior whith this OWNER 1I� ArIDIl�1 C�tDUP � No. 599-6864 �� CONDITIONS • - p
permit is i55ued,I sholl not employ any person in any manner 01 iRICT GROUP TYPE FIRE PROCESSED 6V ()
ADDRESS 629 Covina Blvd• CONST.---- ZO �
'sa as to become sobject to ihe Woikers'Compensa�ion Laws. . , /D ��, � � �����J O
��TY San Dimas z1P 91773 �
DP�e ' Applicant ' STAliSTICAI CIASS�FICAiION A7i. CONDO.
ARCHITECT OR - T L. ,,��
NOTICE TO APPLICANT: If, after making ihis Certificole of �� � ENGiNEER Morano�& Pauli � 2 .347-6555 CLASS NO.�_DWELL.UNITS�� 6W.
Exemption, you should become subject lo the Workeri' L uf
Compenmlion pravis�ons oF tha Lobo�Codr„you must forth- qDDRE55476v Pa� ��a�7 �1��� SBNER M1".AP ?
wilh camply with such provisions or this permil sholl 6e r��+ �*��+�,� �.p�Tm TE� ...
deemed revaked. � �oNTRnC70R 1^r• CLYUGLV laWlJr No. 599-6864 BK� �. VAUDATION
� � LICENSED CONTRACTORS DECLARATION � �i�, �7 o� �. ' . .
I heieby of(irm tho�I am licensed under provisions oi Chapfer 9 . ADDRE55 NO. 3/��/ VALUATION .
(tommencing w��h Sect�on 7000)of�ivision 3 of the Business and ���� S 3(S OOO.��
'Professions Code,ond my license is in full force and e(fect. � � C�TY � -'�' � CLA55 'B � - f '� � ��� Q���;�]A ' -
371580 B 5°EFT.8955 STORR$ 2 F MIlOIES 7 CO EK • #�.�.� �2��
License Number tic.Class {'� �
.n�•.��.IIN IAWUr �TVL�//� DESCRIPTIONOF WORK NEW y`.I S
C❑ontractor Date � 7� 7�3 6
I om exempl from Ihe licensing requiremenls as I om o 7�PLPX CC�1� ADD � . � Y
licensed archi�ect or a re istered rofessional en meer .. nITER � � F�NAL / �/ d � � •7 1�7,3 6� .
9 P 9� . . . . . - . . . ._. ..._ ..... ..... . DATE Sp �V a� � -
a[ling in rrmy profe55ionol copoCity ($eftipn 7051, REPAIR � '
Business ond P�ofessions Code). USE OF F�NA� �O L O��'S 2
• �-�� EXISTING BIDG. - - DEMOL ❑ BY ��
Lic.or Reg.No. Date APv(PRINri T���IN�(�20UP No. 599-6864 ✓ .. . . . . . , .
- ' OWNER-BUII�ER DECtARAT�ON " �+ n� �
1 hereby oitirm thot I om exempt from the Controclor's License qDDRE55 629 Cavina Blvel� J� D1It1a.c�i� 4t� - ' " � � ' '
law for�he foliowing reason�Section 7031.5, Business and
. Professions Code): �� F�iStN� �
suaoiNc �1 4 1,8 A , �
'��" I, os owner of the property;or my employees with � nDDRE55 ,
wages as�heir sole compensotion,will do the work ond - � ,',�� `�' #� � �:� . � .
� 1he structure is not intended or oi(ered ior sole�Seciion � " ��A��Tr - - � � � � � • �
7044,8asiness and Professions CodeJ. MOwNG ' � TEL. . ' ,�.�,2$9,Jr O �
� I,as awner of the propeny,om excl�sively contracting CONTRACTOR - NO. � . '' '
with licensed conlractors to tonst�oct the project(Seo- qDoeeSS � •��2 tg 9,J��c=.�
� tion 7044,Business ond Profeuions Code). - � ' - � �
CONSTRUCTION LENDING AGENCY REOUIRED TOTa.L SETBACK FROM EXIST. - � . �
SET BACK YARD NWV FROP.LiNE WIDTH O 2,O� ���
� I hereby aifirm fho�ihere is a cons�ronion lending agency for� � pqOrvi . ��
the performonce of the work for which this permii is issued p l. _ , . • � .
(Sec.3097,Civ.C.I. .. . sioe....-. .. . .. . '� '�
P.L
Lender's Nome Caltinental Illinois . - �., � _� � • - � �
231 S. La Salle, Chieago Illinois P.G Fee S 17. 3 Permit Fee /.ZP/. �'�. -
Lender's Address � �.�� � � �
I cerlify Ihal 1 hove reod this applicotion and sfa�e tho��he Issoan<eFee �.� � .
abave information is correct.I o9ree�o comply with all County . in.esrgmmn Fee � / � � �
ordinances and S�a�e lows relating�o building construction, � Toiol Fee � _,y�. �
and here outhorize�epresentativez of this County to enier . . . . '
opon . obove-meNioned properly ar inspectiodp�rposes. . . . , . ,
�f/� `../ � � �� SEE REVERSE FOR EXPlANA70RY LANGUAGE . ' �f ,
� . Signature of Ap _on• r Aqen� Doie
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