HomeMy WebLinkAbout0722A 0723A (6) � WORKERS'COMPENSATION DECtARATION �,�� ��G�/ �
I hereby affirm tha�I have o�e.�;F«o�e of consent to 6a�f APPLICATION� FOR �BUILDING PERNiiT
insure,or a certificate of Workers'Compensafion Inaurance,
or d�certifiad copy thereof�Sec.3800,Lab.C.)
��rC�C-956-104-�A COUNTY OF LOS ANGELES 6UILDING AND SAFETY
o�cy o. ompany 3!P'F'Ra 6UILDING �
� Certified Copy is hereby furnishad. FOR APPLICANT TO FILL IN AD�RE55 24206�Sea� een Drive
� Certified copy ia filed with the county building inspec- eUIIDiNG . �
tion deparfinent. ADDRE55 242�6 � �.Drive. � �ocnu�r . Diamand Bar
DO�e ZLIZ�S3 NEA2EST
Appl;can�ZY72 Ai1C�2T1_CYQUA. cirr Diatmnd Bar ziv 91765 cRoss sT. ' h Knob & Golden x'in s
CERTIFICAFE OF EXEMPTION FROM WORKERS' NO.OF BLOGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGf VARCEL
(This seciion need not be completed if the permif is for one TRACT 3 Z BLOCK LOT NO. 2$ u�Z�E NOP ��'
hundred dollars(5�00)or less.�
�cer�ify iha�in the performance of��he work for whicb rhis - owNeR '�'10 AlYC1P.11 �O 71 599-6864 CONDITIONS d
ermit ia issued.I shall rtot em lo an t3on in pn mpqn9l � -- - - -- DIS7RICT GROU7 TYPE FIRE PROCESSED BY �
P P Y Y P� Y • ........ CONST. ZONE V
so aa ta become subjecl to the Workers Compenamion Laws. ADDRESS
!O �f'3 °�
aTr San Diila.s z�r 91773 O
ppla �1pPlicant ARCHiTER OR � STATIS71CAt CIASSIFtChT10N APi. CONDO. F�
� NOTICE TO APPLICANT: If, afler making ihis Cehificate of ENGINEER �V2 $7.dI1 2 .445-4073- p �
�emp�ion, you should becume subject ro the Workers' Cau NO.�OWELL.UNITS a
�ompensntion provisions of the La6or Coda,yo�must forih- qppREu SEWER A4AP � y
with wmpiy with wch provisions or fhis petmil shpll be ?
deemed revoked. CON7RACTOR 7 T� — $ t} BK. PG, YALIUATION �
UCENSED CONTRACTORS DECLARATION . . .. i�C.. ...... .
I hereby affirm tha�1 am licensed�nder provisionc of CF�apter 9 ADDRE55 629 Covina Blvd. No.371580 VALUATION
(commencing with Settion 700D)af Divisio�3 of ihe B�siness and ���. �/5f��
Professions Code,and my license is in full force and effetl. tIN CLnSS E C.(/ �
SQ.R. NO.OF��- NO.OF- CHECK
LieanfeNumber 37158� tiaCl08a B SIZE STORIES FAMILIES ONE
77 NEW � _
Canfro[tor �1E �PSl �DUD�nIe_JL�� DESCRIPTION OF WORK
A�D �
❑I am exempt undar Sec.
AL7ER � FINALt��I�`r, �O7�2A
B.BP.C.for fhis raC7on REPAIR � DATE '(
USE OF #� �• •`2�
�O�e: exisrm�c etoG. oen,wl ❑ �FINAL (��
Br �-C�Jo�—� I •2 2 Q!i 8
Sipnature � APPLICANT � � 71��. 99-6864
OWNER-BUII�ER OECIARATION �tiNi
I hareby affirm that 1 am exemp�from�he Lonuoc�or's License ► • �2 2 a 4��
Law for the following reawn(Sec�ion 7037.5,Business and ADDRESS D�
Profaesionc Code): �2 2 7�$3
..� BUILDING .
` 1, os owner of fhe property, or my employees with ADDRESS
� wOflei os thBir sole compenwtion,will do Ihe work and � �
the strocture is not intended w offered for wla(Section ��`��TY �� � � .
7W4.Busineu and Profeuions Code). MOVING TEL.
� 1,as owner of ihe property,am exclusively contracting RACTOR No. �0 7 2.3 A
with licensed controctors to construct the projen(Sec- qppREu �� � � � •�
tion 7044,Buslness and Professions Code).
REQUIRED TOTAL SEfBACK FROM ex�sr. 3 9 4,5 0
CONSTRUCTION LENDING AGENCY SET BACK vnRD HWY ppOP.LIN WIDTH � � � •
1 hereby affirm that there is a construction lendinq agency for PRONi
the performance of the work for which this parmit is iuued F.i. � •�3 9 4.5 0�
�se�.��,r�.c.�. Continental. Illimis Na ' s�oe � �
_ P.�. � �� I227-83
� ta�er's Noma Rank.� Tnsnt r^ csf (hi�r�rn ry ?p�
$ ze], SS� Sd�.�� �L1C3CJ0� 11�.. 60609 P.C.Fee S 6 Permir Fx ./`�dQ
i nOer
� I cerlify Ihat 1 have read�his application and state that the luuanca Fae !O•.�d
� above informotion ie corr ct.I apree ro comply with.all Counry Inveatigation Fee �� / /d
ord{nonca�ond State la s relating lo building construction, Toial Fee 'S��3
and h ra6y autharize r esentatives of this Counry to enter
� up e above-mentio properry for.inspection purposes. . .. . .. . ..
' w2 3 SFE REVENSE FOR EXPIANATORY UNGUAGE
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