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HomeMy WebLinkAbout1411A 1412A (7) 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 � . , �� ��_.._ - - . • --- , . o 0 � � �. . � ,o � � '� � ° . � � (/� =n ip Q O � p � .O n-p fJ a O P-, � ?' . p O m� n R p ? � O m. � . • ' r ^�.. Q 'y�� ��y l0,� t0 a C� .. T} (� � y U+ p �� .r. 9. 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