HomeMy WebLinkAbout1444A 1604A (15) WORKERS'COMPENSATlON DECLARATION � �
insu�e6oratcerti4icolefolWorkeseColmpenstOninsuran�esolr qPPLIe�►T10iV FOIt BUILDING PERMIT
o certified copy thereof(Sec.3800,La6.C.)
acyNo.534337 �ompo„ySCate ComA. Funr( COUNTY OF LOS ANGELES BUILDING ANO SAFETY
Certified copy is hereby turnished. FOR APPLICANT TO FILL IN ADDRESS Z�'76 P�OClcq V�esv Rd.
� Certified copy is filed with ihe coun�y 6uilding inspeo- BUi�DING �
tion depwlmeM. . ADDRESS 2�.76 i�OC�L' �I12P7 ,�'i�. IOCAIITY ��-�n10Ru $AY
r Aloha oois y�: �iT��iar�ond Bar zia ceossssr "id�e a nd
Da1e 2�3f.�2 Appliw�t � !
CERTIFICATE OF EXEMPTION FR WORKER$' ' � ND.OF BLDGS. n55ESSOR
COMPENSATION INSURANCE � SRE OF l07 NOW ON LOT MAP BOOK PAGE PARCEL
USE ONE MAP
(This�setlion need no�be comple�ed if the permil is for one 30091 1 � l6�� 3��
hundred dollars($100)or less.) . TRAcr BtOCK lOT NO. Z� / NO. y
7E�_ '` SPECIAL �1-
OWNER OI'lll CO�.SI� NO. ] — TO��� CONDITIpNS Q
I ceftify fhaf in the pe�formance of ihe work for which ihis DISTRICT GROUP TYPE FIRE PROCESSE00Y 4
permit is issued,I shpll not employ ony person in any manner qpDRE5513431 Dot Ave. n CO�T. ZONE pG �
so as to become su6ject to the Workers'Compenwtipn Laws. !n �, � �
CITY ' ZIP f� �'
Dpte App�iwnt i ✓ ST.4T�STICAI CtASSIFICATION AM. CONDO. U
ARCHITECT OR TEL.
N0710E TO APPIICANT� If, after making this Certcficate of ENGiNEER ^i.�Fl^r� "o?odzze' No.92+-�315 CWSSNO.�� .DwEtLUNiiS d
Exemption, yau should became subjec� to tbe Warkers' ' ` �
Compensalion provisions of ihe Labo�Code,you must forlh- pD�RE55IZ33O �OSC. St. Cerritos 907QI SEWER MAP z �
with comply wifh such provisions or this permit shafl be �
. deemed revoked. ,' TE��� i � VALIDATION �°
CONTRACTORAlOtI$ POOLS ryp,.E2�i77_ BK� ��
LICENSED CONTRACTORS DECLARATION uC.
Ihereby aff�rm ihai I am licensed under provisions of Chap�er 9 ADDRESS�7O1� `-%.I'ranCi5qU1'CO Np, z 3��1� VALUATION �
(cammencinq wHh Sedion 7000)of Division 3 of the Business ond LiC. �
ProfessionsCode,nndmylicenseisinfulltorceandaffect G7v T,d2E� (,'OV1Tla C�. aL��1C�A55 !)-1? E 1$�Sfj� �r� �� 4QU.A (
2�9��7 C-53 SQEFl.7��' TOR�S AMI�S O EK �� � ���L�
License Number Lic Class �
�[�Ipha �ol " ,� S.a�rrt;in^ ^oI & New a s .
Contracror"�i � +p• a�e 2/�'�82 DESCRIPfION OF WORK _. P- � I. � O Q O O
� t am exen i from ihe ensing reqoiremenh os I am a �'.�a Ao� � � • � � 0 Q�C c=,>
litensed architec�or o regis�ered professionol engineer ALTER � FINAt �� �J�_
aaing in my profeesional capacity (Sectian 7051, REPAIR � DATE �`' ��.�3�8 2
8uainess and Professions Code). USE OF � FINAL
EX�STING BLDG. DEMOI 8
Lic.orReg.No. Da�e APPLICANT��C�4 D7e1� TELr�i�'177' Y
OWNER-BUIIDER OECIARATION (PRINTI NO.%
I I hereby offirm Ihai I om enempf from 1he Coniracior's licanse ADORE53�'7O],� ;.§'rancis nui t0�fy'. �0 71I73
Low for the following reasan(Section 7031.5. Business ond
, Professions Code): 'rRESENi � �
! 6UILDING
. � I, os owner of the properly, or my employees w8h AooRess . �� �. � . �� b Q 4�A
wages as�heir sole compensofion,will do the work and �OCAtiTv � - �
� �he vructure is noi intended or offered for sale�Section � ��� � ��� ��
' 7044,Business and Professions Code). MOVWG TEI. ' . . . ,
� I,as owner of 1he properiy,am exdusively tonfracfing CONiRACTOR- N�� � •� 3 3.5 0
wiih licensed conlroUors fo consiruct Ihe projecf(Seo- qDDRESS �
tion 7044,Business and Profesaions Code). 2
REOUIREO TOTAI SETBACK FROM E%IST. , •'�1 3 3.5 Q�
CONSTRUCTION LENDING AGENCV SET BACK �ARD HWV PROP.IINE WIDTH '
I hereby affirm that there is a construction lending agenty for FaONi Q 2.'{�'-8 2
ihe pe�formonce oi ihe work for wh�ich ihis permii�rz isaued p.t. �
(Sec.3097,Civ.C.�. SIDE
P L.
�Lender's Name (�+��-�, �
Lender'sAddress P.C.FeeS,`�.:J� O Perm�rFee ��s�
I certify thm I bava read this applimtion and state thm the issu ce Fee O •�� -
� obove informofion is correct.I ogree to wmply with oll Counry In�es��gar�on Fee �� .
0 ordinances and Stale laws relating ro b�ildi�g const�ucfion,
and hereby authorize representoiives of�h�s Coumy ta en�er 7o�al Fee 3•,rf�
� upon fhe a6ove-menrioned property for inspection purposes. . � _
$ � � „� �� SEE REVERSE fOR EX►LANATORY LANGl1AGE '
� Sign �re of Appliwn� r Agent -� 0t
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