HomeMy WebLinkAbout1122A (9) / 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 `
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