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�
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