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HomeMy WebLinkAbout1122A (7) / WORKERS'COMPENSATION�ECLARATION ^ APPLICATION FOR BtJILDING PERMIT `' � .� I hereby affirm lhat I have o tertificate of consent to self u msure,or a ceniiicata of Workers'Compensa�ion�nsurance, or a certified copy the�eof(Sec.3800,Lab.C.) COUNTY OF LOS ANGEIES BUILDING AND SAFETY aoucy No. 86490 Company � � I Certified co is hereb fumishe . BUIIDIIVG � ❑ PY Y FOR APPLICANT TO FILL IN . � Certified copy is filed wifh the M buildin ns AD�REu 2735 ROCKY TRAIL ROAD Y � p4- BUItDING , tion depprtmenl. . ADDRESS � $[� CA 1 �� Da�e Applimnt liv ZIP - LOCALITV CERTIFKATE OF EXEMPTIO R M WORKERS' NO.OF BiDGS. NEAREST COMPEN ANCE SIZE OF lOi NOW ON lpT GRO55 5L � (This section rreed not ba co ed if�he permit is for ona ASSESSOR hundred dollars(E100)or less.) TRACT 3OS7H BLOCK LOT NO. 9�F Mqp gppK pAGE PARCEI # �L. USE ZONE NIAP � I tenify thot in�he perfarmance of�he work i�which fhis OwNER �.�p. _ � �O permit is iss�ed,I shall not employ any parson in any manner SpE��µ O so os fo become s�bject fo the Workers'Compeneotion Lows. '4DDt�sS CONDITIONS oo�� Applicom a,r DIAMOND BAR z�r 91765 � NOTICE TO APPLICANT: If, aher making�rhia Certificvle of aRCH�TECfOR TEt. D�STR�CT GROUP ttPE FIRE PItO�SSEDBY O NGtNEER NO. �F- H O Exemplion, you ahould become subject to 1M Workers' CO� F- Compensation prorisione of tha Labor Code,you must forth- `,.! W with Comply with auch pravisions or fhis perrrlit aFwll be A��� ��Q S. PINEFALLS AVE. �Q m V N � deemed revoked. CONTRACTOR PIERMARINI ENT, r�i�o. 594-4800 STATISTICAI CL4S IF�nrioN AM. CONDO. N LICENSED CONTRACTORS DKLARATION �yqu Np_ �d- Z �, DWELL.tlNIT$ I here6y affirm ihof I om lica�sed under provisions of Chopter 9 ADDRE55 (commerxing wi�h Sec�bn 700p)o{Division 3 of rhe Business end LIC. ��R MAP Rofeesions Code,and my hcense is in full force ond eRect. Cm � CU55 BK. PG. VALIDATIDH 5(7.FT. NO. NO.OF CHECK licanse Numbar 283724 �;�.��a„ Bi s¢e �QdO sTORies vs,mn�s 1 arre VALUATION eo�nacror PIERMARINI ENT. oore DEKRIP710NOFWORK NEW S /�QO O� .,w1 ADD � � , �I am eaempf undar Sec. w�� STORAGE ROOM 4i�1rr p�TER B.&P.C,for rhis on �� � �PA�R ; Dafe: � E X TN G&DG. � oEMOI ❑ L� �2 Z A ! Signature A��UMNT �MA�,�No. �0 FINAL �• •�r 2 3 ER-BUIL RDECLARATION ' �'�'"y'�"�' DATE I hereb th �m exem(t frvm Ihe CoMroclor'a license pppReSS O S• ��T h�s W 11'� flNp� • 6 •9 j,'J 8� Law for e fo wi reuwn Section 7031.5.Busines�a�d a�2 8 Y 8 7 Profassions ode): - -- F2E ENr yp � �,aa owner of the propeAy, or my employsn with ADDRE55 wages a�their sole compenwfion,will do�he work ond � the slructure is not intended or offared for�ale(Section ����TY 7W4,Businees and Professiona Code�. n�OViNG TEL. � I,as owner ef rhe property,am sxelualvely eonhaeting COI'1TRACTOR NO. with Ilcenaed tonha�tan to mnstrue�the projeef(Sec- Ap�� . . �ion 70M,Bminen�and Profeasfons Code). CONSTRUCTIpN LENDING AGENCV SETOBACK YAR� NVJ1' TOTAP OP LINE WI�TFI �/� � I hxeby affirm thpf 1i�ere i�a cnnrnuction Isnding oQenCy for FRONT iJ[,f'� G�s��j the performance of fhe work for which this permit b txued p,t, y -�" (See.3097,Civ,C.). SIDE P.l. lender'e Nama g !D `rn LCMA R•f.M Lender't Addreas P.C.fw f P.mn fv� / .1 � , � I cerlify fhaf I havs read Ihi�applltallon ond eMle fhat ths lauanc�Fw /��� LpMA P/C N e obove Infamation la eorron.1 agree to comply wl�h all County Invaftipalion Fss �) 7� ordinances and State laws relating io 6uilding comtruction, Torol Fn ' V V IDMq P.rm.M R and hme6y authwi:s reprsasnlativea of this Covnty ro entx � upon Ihe above-manrloned properry for inapection purpoees. � m SFE ItlVERSE FOR EllrLANATORY UNGUAO! ' Siqraturo oh Applicon�or Apen� ppb ` --- — --- --- --...--- — — -- -- -- ----�- -- --- ---- ---- --- --- — , m T r'. _ m T !n �-- r �T ::- �:: �� — v � �r• -T� `1 � ' � .: !l= C O 7 O v'` _ `,,, ? ,"�D - . �' _ '_' _ O O � ^ O O � � ,.� O � ; t0 � F I O � .�' � ?i ^, __ � � �L I � - � �u � 7 � �� .� ❑�o D �j ,-',o � � � - _ �L X �� � _ r] � I _ _ �' O ^. ,,. U T� i � T .n• ,'� r - R O ' n ' .._ Yj _ � �I` I o �?�) : l o � N � o � c �n � � O m , p � o O . 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