HomeMy WebLinkAbout0732A 0733A (4) � WORKERS'COMPENSATION DECIARATION ���'1 ��� �
� I hereby affirm that I have a�certificote of consent to self � APPLl-C�►�'�� �o� �����D��� ��.\■�\'� �
Y insure,or a cerlificate of Workers'Compensation Insurance,
� or a certified copy thereof(Sec.38W,Lab.C.)
��3—C�C-956-104—C�A COUNTY OF LOS ANGELES BUILDING AND SAFETY
�= o icy o. ompany�p{�y� BUILDING �
� Certified mpy is hereby furnished. FOR APPLICANT TQ FILL IN 4D�RESS 2 zl FL7. Y; ROdCl
� � Certified topy is filed with ihe county boilding inspec- BUILDING -
� tiOn deporlmBM. ' AODRE55 LOCALITY D� � $aY'
c Date 11/2/83 Applicont `l�'t2 Anden Gr'oup aTr Diairond Bar ziP cRossSST. Hi h K�wb & Golden S rin s
CERTIFICATE Of EXEMPTION FROM WORKERS' NO.OF eLDGS. ASSE550R
� COMPENSA710N INSURANCE SIZE OP LOT NOW ON l0T MP.P BOOK PAGE PARCEL
(This secfion need not be completed if the permit is for one uSe ZONE MAP
; hundred dollars($100)or leu.) � � TRaCi 3302 B��K �oT No. 33 No. .:Z - s� -
T SPECIAL
�I certify that in the performance of the work 4or which ihis OWNER '�1e �I"1CZeY1 (�O 71 99-6864 COnloI710N5 �
� �permif is issued,i shall noi employ any person in any manner , oiSreiCT GROUP TVPE FiRE PR ESSED BY �
so as to become subject to ihe Workers'Compensation Laws. /+ooRE55 CONS� ZON� �✓
7
.CITY San Ditras, � ZIP 91.773 �� �� /� �
� Dote Applicant - --� SiATISTICALCtA55IFlCATION APT. CONDO.
'?IOTICE TO APPLICANi: �f, after making ihis Certificafe of /+RCHITECT OR . E.
�,� 'xempTion, you should become subject to the Workers' ENGwEER �c1VA 52d.T1 21 45-4073 C�4SS n10. c�-�'' oWEti.UNiTS"�� �
�
'Compensation provisions of the labor Code,you must forth- �'
a�ith comply with such provisions or ihis�permit shall be /+DDReSS ' � ' sewea nnp,p
�
� deemed revoked. CONTRACiOR The 1-lnden�Gro � 7 T �.599-6864. eK. Pc, vau�nnoN
� LICENSED CONTRACTORS DECLARATION ' ���,
��� I hereby affirm fhat I am licensed under provisions of Chapter9 ADDRE55 �29 �'AV711c'l B�AC�. r,o.371580 VALUAT�ON '-
�,� -(commencing with Section 70�0)of Division 3 of the Business and ��� /��
�Professions Code,and roy license is In full force and effect. � Ciiv G j�' CLASS $ $ �`�"��J �
- SQ.FT. NO.OF NO.OF CHECK
�License Number 371580 u�.c�ass B - size 1970 sTaRies 2 FnMaies 1 oNe
-.COntfaCfOf �1'iP Anr�an�C;r rn�mDate ����P+� DESCRIPTIONOFWORK
NEW � $
- ❑I om exempt under Sec. � � __S]11 le famil� r].pIIl2 Aoo [�
� �- ALTER j] FINAL �
B.&P.C.for this reason REPaIR � DATE �I,�.$���--� ��Q 7},Z Ft�
USE OF �
Date: DEMOL BINAL #f + •L,�
� EXISTING BLDG. ❑� � s �
� $ignafure �- �APPLICANT T L y �`-'�J
� _ PR�NT� u 7 599-5864
OWNER-BUILDER DECLARATION I +7�G F�11 B
� I here.by affirm thaf I am exempf from the Coniractor's License
� Low for ihe following reason(Seciion 7031.5,Business and ADDRESS. , e�����4(j g U
� --Professions Code): � � pRESENT � 2�G 7'`g 3
� �BUILDING
� 1, as owner of th e pro p e r t y, o r m y e m p l o y e e s w i 1 6 A D D R E 5 5
� wages as their sole compensation,will do ihe work and . . ,
ihe siructure is not intended or offered for sale�Section �OCALiTv
7044,Business ond Professions Code). MOVING TEL. �(�j 7 J,�J A
� .� I,a s o w n e r o f i h e p ro p e r t y,a m e x d u s i v e ly c o n f r a c t i n g CONTRACToe NO. *
wiih licensed coniractors to consiruct the projeU�Seo- +�° e ° °� t�
; tion 7044,Business�and Professions Code). � ADDRE5S
� - REqUIRED TOTAL SETBACK FROM EXIST. � I �v�J�.J�Q
CONSTRUCiION LENDING AGENCY SEi BqcK YAao Hwv pROa.twE wio7H
-� I hereby affirm that there is a construaion lending agency for pkoNi �// e e��_(�;rj'.��
n the performance of ihe work for which this permit is issued - p.L �`*' S�� ��
" �se�.ao9�,a�.c.).Contanent�l Illinois Natio s�oe S--i � �; �S' '
s m P.�. 1 2.27ffi�3
� � _Lender's Name.BdtljC�&' TY'US't CA. Of Q11CdQ0 /� �}.`
� ^ -23� .5. Zc1 .Shcle .St..� �11CdC_(O� I�..�.. 60609-.. o.c.Fee s te�,'�d� �� Permir Fee ��T T�/t�
len er's Address -
rc =I�certify ihat I have re this opplimfion and state ihat ihe _ ���.Issu ce Pee /��C�
� ¢ above information is co ect.I agree to wmply with all County Inve:iigoiian Fee an
. � ordinan es and Sta�e 1 s relating to building�construction, ��r�_,r.��P
� and r by authorize r presentatives of ihis Coonty to enter Toml Fee
m --�po 1 above-me}�K rarerly for inspection purposes.
$ d
��83 SEE REVEBSE FOR EXPLANATONY LANGUAGE
ia � Signature o Appl ont gent Dote �s
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