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HomeMy WebLinkAbout1528A 1529A WORKERS'COMPENSAiION DECLARATION 1 heraby offirm that i hove a cerlificate of�o�,a��,o sa�f ��,� APPLiC�#TiON- FOR BUILDIfVG PERf1AAIT Il inwre,or a cerfitico�e of Worken'Compenaation Imurance, . or o cerrified mpy theraof(Sac:3800,Wb.c.� [OUNTY OF LOS ANGELES 6UILDING AND SAFETY Poliry��956-10��r AEi'NA - . . aCertified copy is hereby furniahed. � FOR APPLICANT TO FILL IN �1�tDING ADDRESS 24234 SEAf.�2E�i DR. � Certified copy is filed with ihe counfy building inspec- BUILOING tion depanment. ADDRE55 24234 SF�IQ2EQ�I DR, iocnurr DIANK�ID BAR Date 1�23 H4 NEAREST f Appliwnf THN. j�[��] Q2(1TiU qTY ZIp CRO55 ST. CERTIFICATE OF EXEMV�ION FROM WORKERS' IVO.OF BIOGS. q55E550(t � COMPENSATION INSURANCE SIIE OF LOT NOW ON LOT MAV BOOK PAGE PARCEL (This section need not be�complated if fha parmit is for one USE ZONE M1V+P hundred dollari(�100)or less.j � TRACT BLOCK LOT NO. .'t.��,�� TEL SPECIAI I certify tkqf in the perfwmoncs of th�work fw which thia �`�'�NER NO. — CON�ITIONS p�, permi�is issued,I shall nof employ any person in any manner �ISTRICf GROUP 7YPE fIRE PROCESSED BY 0 w as ta becoma sub'ect fo the Workers'Com A���� CON ZON V I pensatiOn lows. /a �� � � � Dofe �. . ApPli[ant � . ��HL���8 .. ZIP.:�1.,. STATISTICAI C1q551flGT10N AM. CON00. O � NOTICE TO APPLI�ANT: If, oftar mcking�this Cerfifiwte:of ENGINEER LJHVE.SZANY��.-� :.�...- T16. .. �'.QO�I3�- .��Np. �O. DWFiL.tlNliS�� Ivyi aemption, �you should become��svbject-to�the Workers' � a �ompensotion provisions of the lqbpr Code,you m��t forth- pppRpu314�N. ���+�,A�...��� +�� . . �R�qp. , . y� with comply with such�provisions w Ihis permit ahall be� �_ . . . . ..- � . . Z deemed revoked. � � � — UCENSED CONTRACTORS�ECLARATION �7�R� �� — . BK.� PG, VALIDATION UC. I hereby affirm thot I am licensed under provisions of Chopter 9 ADDRE55 �10. YAIUAiION (commancirg wilh Section 7000J of Diviaion 3 of the Business and IIC. Profaations Ceda,ond my license is in fuli force and effect. CIN �VII� CU+SS $ s 6q 850 � � SQ.Ff. NO.OF NO.OF CHEGK � LK9nseNumber 37�84 UaClpsf $ SIZE STORIES ]. fAMILIES 1 ONE SCRIp17 1��� NEW 5 Contracto�mc� ntti,�r;u�T r_orvm om.]����54 DE o woaK CONSTRUCTION A� ❑I om exempt under Sec. ALiER ❑ Futn�� �1 5 2,8 A B.&P.C.for this reoson ' � DATE �(y(8� REPAIR Date: E STING BIDG. p�p� � FINAL #�� � •2� ey C�.�,_v--� $ignafuro . A7PlKANT TEL. � •L 2 3.� 3 ' ��OWNER-BU�LDER DECLARATION �t�NT �.�p, i I harnby affirm�ha�1 am aaempt hom the Conhacb(s Licenae ADDRE55 1�74 pA� �� �r �a �a , � �2 L'A� `3� I� law for the foNowing reason�Section 7031.5,Buclness and r � � � Profeaaions Code): Prte 0 2 1 3—8 4 " � I, aa owner of tbe r BUIIDING ! p aperry,or my employeea wilh qppRESS l wages as their sole comperuotion,wiil do�he work and the strutture is not infended or offered for wla(Section ����TM 70M,Busineaa and Profeuions Code). MOVING iEL . c' V��� � I,as owner of tha praperfy,am exclvsivaly coniracting NiRACiOR NO. - with licenaed contracrors to conatrucf fbe projea(Sec- ppoRE55 #• •• . �� lion 704�,Business and Profeasions Code�. _ REOUIRED TOTAL SETBAIX FROM EXIST. CONSTRUCTION LEN�ING AGENCY SFT BACK Y'� H'� PROP.UN WIDTH . - . I •3 8 5 5 U I hareby offirm thm there is a cons�ruction lending agency for fRONT I'' the parfwmance of the work for which this permit ia issued P.t. Y'" �� ► • •3 8�5 0 c=i i5ec.3097.Civ.C.). S�DE — '` S� /�� 0213-84 Lander's Name `� P.G Fee S q-�-3 �J Permit Fee 3�J� �� . Lender's Addreas ' � I ceni4y that 1 have read this applicntion and state that the issuanca Fea /O. �:U � a above information ie correcl.I agree ro comply with.all County Invesrigo�ion Fee � ordinantea and State lowa lating ro 6uilding construetion, Toto1 Fee .j p.5��v lY and hareby authOrize repr entalives of lhis County to enfer � upo obove-mention properfy for inspection purposes. �/��� /1�- SEE REYfYSf FOY EXPLANA70lY IANGUAGE ' Signawre App icanr ar em � po�a t �� ,.- - :. N ' _ .I�'y �. V � u�v S t . . . . v 0/� � ...'�'" x�``� ° � 3 '" o ° _ T.." t C� .C y C � �y .� • . , w .a o'� � Xc�, '��'co"� 3 °o ���m,,i+,M:x °' p o � ��, a,�� � U _ ,,n M.h � � C� o � u O h . M a, cs.: n w � " � i�n- `, . 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