HomeMy WebLinkAbout1411A 1412A WORKERS'COMPENSATION DECLARATION . ... .. . . ' � �
I hereby offirm thot I have a certificata of conseM fo self APPLICATION F�R BUILDING PERMIT - �s
�insure,or a cerfifita�e of Workers'Compenstion Insurante,or , �
er� ih f(Sec.3800,La C.) ` COUNTY OF LOS ANGELES BUILDING AND SAFETY
������8'�-�3�� �rgonaut -
o�licy o. Company BUIIDING
i CerrHied copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 55� '�O1C�1 $ S �I'. �N�X�)
(�1 Cerfi(ied topy is filed with ihe county bullding inspeo- BUILDiNG �}1�i�I1d Fj'd�
UU tion deparlmenl. AODRESS 550 Golden S rin Dr. �ocaurr
' 7-14-81 TI� AI�IDIN C�tOUP Di�tond Bar Z�, 91765 . c"Ross sr. Stmset Cross'
. Dote ApplimM � � CItY
CfRiIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BlDGS. ASSFS50R
- COMPENSATION INSURANCE � SIZE OF l0 -u NOW ON LOT MAP BOOK PAGE PARCEL
(This section�need not 6e mmpleted if�he permit is far one v o USE ZONE n�AP ,//�
hundred dollars(S1D0)or lesz.) � - , TRACT _ BIOCK lOi hp1�s. .7� �',j NO. �3�3`f"% r
. TEL. ��.—t�(J SPECIAL � p,
1 certif that in the erformonce of ihe work for which this �WNER � A�Q ��� �.599-6864 . �oNo�T�oNs � � �o
1' P DISTRICT GROUF TYPE FIRE PROCESSED BY V
permit is issued,I shall not employ any persan in any monner q00RES5 629 COV1TId B�-�• . CONSi. ZO�N� �
sa as�o become sub'ect to ihe Workers'Com ensarion Laws.
I P . . CITY 'S2LL D]SO�.S ZIP 91773 � �° �� /v ���� �
Dole Applitont STATISiICAL CLASSIFICAJION APT. CONDO. V
NOTICE TO,APPLICANT: If, after moking this Certificote of-' NGNEEeiOR hk�r�vo & Pauli�- 2� 347-6555 CLaS5N0. �f DwE0..UN1T5� ` a
Exemption.�you should become subject fo the Workers' �n
Compensotion provisionz of ihe Labor Code,you must forlh- � qpDRE55 4766 Park.Granada C2.1�2S2S $CWCR MAP z .
with tomply wifh such prorisions or this pe�mii sholl be TE� .
deemed revoked. � � � cONTRnCiOrt � �� �� No. 599-6864 BK. PG, -VALIDATION
. IICENSED CONTRACTOR$DECLARATION LiC. 37�r� � - -
I hereby otlirm thot I am lice.nsed under provisions of Chopter 9 ADDRESS - �� �� NO. VAIUATION
(commencing wi�h Section 7000)of Division 3 of ihe Business and LIC. . _ . .?�.�1�.� {l.- ... --
Professions Code,ond my license i:in fuil force ond efted. ., . Giv. -Ctn55 B- � s 365)Q�O.��
_ . ... ._._..__... ... . . . -. .. _.
SO.EFi. p�5� 5 ORIOES Z AMI�tIES 7 CO EN #•i •,�Z��
License Number 3715� �Lic Class B �� � � �
111L LflYle:.lY lMl��p �// DESCRIPTION OF WORK NEW � S �I •71 7,3 6 � •
Confraclor i5ote � /$'� _, . � � ;
� I am ezempt irom ihe licensing requiremenis a51�om o 7—p1PX C�C711dO� � A�o • •7 1 7,3 6�: . i
� licensed orchiteCt or a registered professional engineer . . . . _ . . .__ A�tFR_❑ f�NAL (�
acring in my professional copacily (Section 7051, REPAIR � DATE � �� d� �2�� —fj 2 ^ '
' Business and Professions Code). USE OF . FINqL � ' � 1 �ti
- - E%ISTiNG BIDG. DEMOL ❑ By - ` �
Lic.or Reg.No, Date APP�P N,� 'i�-ANDEN (�pUp _. No.599-6864 � �-
OWNER-BUIL�ER DEClARA710N- ��7 � �
• I hereby oHirm ihm I am erempt from�he Conhactor's license qDDRE55 E)�L9� COV1Tla BZVu Sall D1ID8S � �r ��
Law far the following reoson(Se[lion 7031.5, Business and Il . .
ProfessionsCode): FkESiNi , ' �� 4��,2R
BUILDING
�� 1, os owner of the properfy,��or�my employees with AD�RE55 � � t ,�s �,e • .;�
wages az iheir sole compensarion,will do the work and , � ':
� Ihe sirucfvre is not intended or oifered for sole(Seclion ' tOCnUTV � � � •
7044,Business ond Professio�s Code). MOVING TEI. ".".�- � �'�8 9,`S Q
� � CONTRACTOR. - �NO. - - � � - - . ,
I,os owner of the propeny,am excl�sively canlracting •.�,L S 9�5 O�
with licensed mntratlors to mnsnuu the project(Sec- ��_..�.1.�- �.>- . , . . . �
. lion 70dd,Business ond Professions Code). ADDRE55 . � , • �
REOUIRED fOTAL SETBACK FROM E%ISi. O 2 O� �82-
CONSTRUCTION LEN�ING AGENCY SEi BnCK �ARD Nwv FROP.l WE wiDTH . , ., - �- .. .�
I hereby aff�rm�hol�here is a construciion lending agency for� �-� � prtONr � . ' '
the performance oi Ihe work for which Ihis permit is issued P L " , , - . � : � -
.(Sea 3097.Civ.C.): _ . . . ... .. Sioe - - � � . � - , � , � - -
P.L
lender's Name �CCl1t71r1.Pt_1�1t31. T1�121015 , � . p '- . -,. _. . ' .. . � . . �
23�- .S L3 .53�.�.e� 1�111CflgO IL1711O].S P.C.Fee 5 l /�.3 Permf�Fee �4/. �� � . , - - � : ��
�ender's�lddress
,.�� � ' �
I certify tha�I have read thls application and stale Iho1 Ihe Iszuanre Fee ' .
above informai�on is mrrect.I ag�ee�a comply with alI Counry , , i,,,,eseyoron Fee - pa � � � � � �
�ordinonces and Sia�e lows relating io building con5lrVtfion, To�ol Fee ���T/•S� '
and here authorize represen�mives of�his County ro enrer . _ . ' '
upon abo�e-mentio ed praperty io��nSpeUion purposes.� . Y , _ • .,
�� � "i�a.+�i �A � SEE REYERSE FOR EXPLANATORY IANGUAGE ' ,� � � � � � � � •l
- S�gnoiure of Appl' .m Agent Dore � . , ��
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