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HomeMy WebLinkAbout1275A 1276A , _ , -" WORKERS'COMPENSATION DEQARATION . �� '� �� - - - _ , �y ` � ' PPLICA�ION-F�O�t BUI�DING PERMIY � I�hereby � at I have a�cerlificate of conseni to If /� iasur r c h' te of Wwkers'Compensation Insur ce,-�� '�� "�"��� " or cer ' d op�t ereof(Sea 38W.lob.C.f :.�:. ._. ...... .___ .._._.:.---'----;• _.._-_ .:__... �,.-.... ..,, COUNTY.OF t05 ANGE�ES__ BUILDING AND SAFETY olity . - 6ompany ... BUILDING ' � �i�f� d opy u hareby for�d. . ,.. FOR APPLICANT TO fILL IN �Eu g^ ❑ � rtif cop iF filed with the county building irispec- - BUIIDING f� d e nl: . . .. ADDRESSG �� Da -ApplicnM � .. ... . CITY ZIP �p('qUN � CERTfFI TE OF EXEMPTION FROM WORNERS'-� ^��- - -- �� ` ���&�5� � ��- -� - �-- - - • - COMPENSATIOEV INSURANCE�- , . . . SIZE OF l0T NOW ON LOT CRO55 ST. �-�T .. .�..� . . Qh �settia eed no�be complated if the permit ic for one - TRAC7.. :/.. .BLOCK lOT NO. � �ESSOR .... .. � hun Ilan(ZIOQ�pr.less,) � . . . . . hWP PAGE PARCEL . . . . . 7EL � MAP � . I.certify thot in the performance of the work�for which this � OwNER - �"� �'" " � ��NO. � � NO � permit is issued,i ahall nol employ any person�in any manner ,.__ _ � �7 .� 4 � �1�.. __ � ' � ��A�� � �� � � So os to lxcome subjetl to iha Workers'Compenwtion Laws ,+ j J� CONDITIpNS .u � _ - .�.. . . . -� . .. .. - ....� . ...__ CIIY- '•I[LLGi-. . .Z ZIP 1`-'Gv./ � . � . Dofe ' � APPticont '� ..� . .;. p�I�R. ''^ TEL : -�NOTICE TO APPLlCANT:-It, oher moking this Certificole of N INEER "Y`ini yi�. NO1f�{(g��{.�� -aSTR1.Cf . _Si UV�TYPE FIRE D BY � �` emption, you should 6ecome su6ject to tbe Workers' 1 ( V . ,. WIVS .P . -. .. . nmpenaario�provisions of�ihe Lobor Code,you muzt forth- qppRE } � f lY'JI.�Z I � � -'` --�� -0^ �wifh tomply wi�h�such prnvisions w..ihts permif shall be . - _. . ..-..... -`.. '--... ... . . .- � � deemed revoked. - - . � � �� � iE�. ` STAi�5TIG4L 1� OH �� RPT. � C(>NDO���- � . . . ...., . .�..�-..� CONTRACTOR ND. . ... . _. ..... .� LICENSED CONTRACTORS QEC1ARAilOM `. � .. ... . iK. � C1A55 NO... .. .WELL.UnliTS� I hereby aNirm tfwt 1 om I�cansed under prov�s�ons of Choptar 9 ADORE55 nio. �� (commencirg with Section 7000)of Division 3 of the 6usir»ss ard . . _. . .1�:-.. . . ,: SEWER�MAP � � � . . , . _.... .. . . � Professions Code,and my�icense is iri,full force ond effect. CIN ClAss ' �.-----�---.- - VALIDATION - . - � ' --�--"�--- - �� SQ.R. NO.OF NO.OF CHECK � � ...`` . ... ...�. -- � �.. '-'"='��` � � SIZE .. .�._ ....-STORIES FAMILIES � ONE " LicenseNumber " -� --. -Lia Ctass � -��tAIUATtON� �- � -"� " z 1 2 2 5 A� , .,,. . . . .:.. . . . . . .-: . ..,..... _._._..-- DESCRtii101VOF wORK .. . .. NEw... . -- � --..... . �. . . ...- .............._. . �. �^7.. �,w��� � ' Conhattw .. DPte � /.- A� : � f� "7.LJC;A� � #• • • ��3 ❑i om exem t under Sec. -' ' � ��-W � � � .. P nihR . I •399.08 • -. ._... ...._ _ 6.B�P.C.fOr(I1�5 rB050� . REPAIR ��i � - . _._ _... ......._...... �� USE OF � . . .. . ` - • �v G�t.G R� . Fe: EXISi1NG BL�G. ��L ...... � �Q-7p�L[� APPIICANT . �,.1 iEl. .-J�. j .__ _ ___ ' ' ' - . SignnNr PRINT t✓V�1 W�. N0�1'�(Oi,i^ . .f{/JAL yC �. . ... �d .. . � � � _ . DASE �ed " � 1 . �, 9 ... . p�., . . .. ...., nse ADDRES5�7�� Gt>. -'1Jf�t_+�t-1;`�' n��.�!t Fuuu '�1 2 7.6 A � i . low fw ihe fol4owm reosun Sectian 7D31 5,Businesa ond �j ��� I hwe oHirm Ihot 1.am exam fr the Contractorls l�ce . _ .. ., _ :�. _. . ... .,�,��s.�-a s� _�-�. NER-BUILLIER .. 'Profeuions Codej...... ..� . .... . . .. . . ... ... ._..T_l%_ ..,_. . � BUILDING ... . I, as owner of the property,or my employees with ApDRE55 . t ...�,; '•�, � [�'�2 O Q � • I � waqes as tFieir sole compensotion,will do�he work ond � .� . i _ � iocAun • •9?7.J0� . the atructure is not i�tended or offered far sale Section � x 7044,Bosineu and Professiom Code). MO�iNG h�� � �� � � I,as owner of Ihe properry,am exclusively contracting . ����� �' ' - ----- ., � , �2.2 2-�b � with li[enaed conha[tora fo[Gmlruci Ihp projett($eo - ADORE55 �^ . tian 7044,Business ond Professions Code)• , ..�,i"'.� . ....... . ..CONSTRUCfION LENDING AGENCY SET�&4CK... ..YARD r+wr. Tar pq�.tME w�oni�- ". . - , 1 hereby aHirm that�hera is a construction lending agenry for FRON7 . . � � � ��he perfwmance oi�ha work fw which this permit is issued -----� --P.t.--�--- ----- ------ � _ � (Sec.3097,Civ.C.J. SIDE � � ' - P.L . . . . . . . � $W lender's Name � . �� � � IDMA Ret.1► � �. . . � � � P.0 Fee i - . Permit Fae �- � ' -� � Lerder's Address .� . '-.�. ..,...._. -.- � 1.cenify that I have read.this opplimfion ond state thm the � .Q iu„o„�e p�e -� .� -�lDtiw aic 1F � � obave infamolion is careci.1 agrae to mmply with all County . . . - -..- ,_ _ . .... g orclinances and State laws rela.tinp.to building Gonstruction� ... � �g.� To�ol Fee ..... .. "- -.. -� IDMO,Perm'r"M..�� . . .. . u nnd hereby authoriza representativea of this County fo enter � � � upo the abova-m nlioned proparty for inapeclion purposes. ,/�� �y��� ; - � I (/� I<��I K1K3 SEE YEVEYSE FOY EX�TO�Y UNG1U1 E . .. � �-Si9rabreo4 plicvntorA9e^r- Dors . ... . . ..____.�_�S) .__.._._. . � OO� � � .�^�. N •,y+ M L . y � � p�,N C� H M ��:� ' . . -. m C �. �� p� �e o T•• %�: t C'v���.'�,. w � c, � O u � �.�.,.,N V . '^ �[1 .Y�"S"' V v�0 y+��:�p N Y O .r.'� C � 3 '^S i�` 0. u O O p i� � , �� . C � . 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