HomeMy WebLinkAbout0813A _ . _ _._. _ ._ - - _
WORKERS'COMPENSATION DECIARATION � '�� --� - � �� . �
I hereby offirm rhat I hove a certificate of tonsem ro self �
,�,�,e,oracertificotaofWorken'Compensoiion�n,�,o��e, APPLICATION FOR BUILDING PERMIT
• or a cenified copy thereof(Sec.380p,�ob.C.1 ' - -� 3/B COUNTY OF LOS ANGELES . BUILDING AND SAfETY �
7ddrJ�9A5-279-04��Pony Nationwide
❑ nooae"ss 620 Pantera Drive
Ce.;ified copy is hereby fumished. fOR APPLICANT TO FILL IN
�� Cerrified copy is filed with the mvnty building inspeo- �". BUItDING
tion deparfineM: AD�RESS
Date R�j�R 7 ApplitaM P Qt � .. . . ZiP ioGAUTv .
CERTIFICATE OF EXEMPTION FROM WORKERS' � �� � � - NO.OG BL . � � � NFARESt .
COMPfNSATION INSURANCE ' � SIZE OF l07 NOW ON tOT CROSS ST. '
(This seciion need not be completed if the permif is for one , quEupg _ _ 1T1Cf5
hondred dollars(EI00)or lesi.) TRACT BLOCK LOT NO. MAP BOOK�� � PAGE PARCEL
TEL. U ONE �P �t 2•�
I cedify ihot in�ha performonce of the work for which this owNER N � ! —yY-
permit is issved,I sholl not employ any person in any manner poDRe55 gO�7 ���A�- -� � - - �� - � —
so as to bemme subjed to tha Worken'Compensaiion laws. CON��nONS 0
� .. . �� '� CIN Z(P V
�te - ' A II[onf � ARCHItECf OR TEI. DISTRICT GROUP ttPE FIRE PROCESSED BY_ �
.ziYICE TO APPUCANT:pf oifer�moking�this Certificale of ENGiNeER NO CDNST. - � 20NE � �
Exemptlon, yov shovld becoma sob�ect to�the�Workari 1� . �
Compensotio�provisions of ihe tabor Code,yoo mvst fonh- qDDaE55 � W
wiih compty with svch provisions or this permil shall be �-�-- �� ������- � �� - d�
TfL. STATISiICAI CLA55�ICATION APT. C NDO. �
deemed revoked. � �� CONTRACTOR O. Z
LICENSED CONTRACTORS DECIARATION� � � � i��;� - � - �-tASS NO. DWELL UN�TS �
I hereby affirm Ihat I am litensed under provislons of Chopter 9 AD�RE55 .
(commendng with Section 7000)of Division 3 of the Bvsiness ond _ . . . .���, . _ SEN'ER AMP
Professions Code,and my license is in full(orce ond effect. , p7y CtqSS B --'� -BK� � - - - - �� YALIDATION�
SQ.Ff. NO.OF ND OF CHECK
�icense Numher 510 5 6 0 - ua Clase R s�ze 14 0 9 sTott�es 1 FAMILIES 1 ot�e
THE ANDEN GROUg 8/5/8 7 - oesceirr�oN oF woaK ' "Ew
vawanoN
conrrocror ate �S
� 462 $r' ADD ,
I am ezempr under See. G1rd 2— AITER� � P 0 8-1.3 A
8.8P.C,for this reoson SLAB ONLY REPAIR � f � � #• • • • •�
oo�e: use oF oenna ❑ I+ •7 U,2 5
EXISTWG BLDG. .
- Signature � .. . . . � ' ^P�iCaNt TEI. F�NAL /�/
OWNER-BUILDER DECLARATION • PRWT -.DATE ls � J D . • • •7�2 Jr c=i
� �I hereby affirm thot I am eKempt from the Contractor's Licensa � � �-j{S dbOV2 � � - � - �
�ow for Ihe following reason(Section 7031.5,Business ond ADDRE55 FINAI O B.� �T"'$7 �
�f055i0n3COdBJ: . . . .. ..... . .. PRE EN sY / �.. ' . .. . . . . . . . .
� t BUILDING
I, as owner of Ihe property, ar my employees wifh ADDRE55
woges as their sole tompensation,will do the work and ��TM � . � .
tha slroctvre is nof intended or offered for sale(Setlion � � �
7044,Business and Professions Code). � �-- - - � � MOVING - TFI. - - ��� �- - �� -� - � � -
� I,as owner of the propeny,am exdusively contmcting GOMRAQOR NO. . ,
wi�h Itcensed contracmrs to conztruc�the project(Sec- - �--�- - -- � � ---- �-�--- ---- - -- � - � � -��
tian 7044.8usiness and Professlons Code). ADDRESS
�� � � CONSTRUCTIONIENDINGAGENCY � � -'�Qgq�K YARD NWY TOTAp�SE�TpAINEFR WIDTH � � � -
I hereby a(Firm iho�there is o constroction lending agency for FaONT � �
the perio�manca of the wo�k forwhich lhis permil Is issved P.l. - - � �
(Sec.3097,Civ.C.). SioE �
. . . P.L. _ . . .
lender's Name Citibank � � �
IDMA Ref.S �
Lender'sAddress444 .S. Flower. L.A. 4��7�. PC.Feef Perm�tFee ,
.1 certify�hvt I have read thin applicatian and tlofe�hat iha . Ivuonce Fee .�'O•5� IDMA P/C M . .
above in(ormotl is corcect.I agrce fo comply with all County � i�„esiigaiian Fee
ordinoncee a tma laws relating ro building consiruttion, _. Toiol Fee 74•25 I�MA Perm:N -� - �
and hereb orize representotives of Ihis Coonty lo aMer � '
opon th tianed properry for inspectlon p�rposas. � �
� SEE REVFRSE FOR E%►tANATORY UNGl1AGE
S�gnmuro o Applicanr or AgeT D_� . . .. . . . . . . .
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