HomeMy WebLinkAbout1522A 1523A (13) WORKERS'COMPENSATION DECIARA�ION �
� �a�ab�affi�m that I hove a certificare of tonsent to self �� G APPLICATION FOR BUrLDtNG PERMIT
insura,or a ceNi4icate o4 Workeri Compensotion{�uronce,
o�a� ,�s�ed copy+n r of Sec.3800 lab.C.) �pUNTY OF LOS ANGELES BUILDING AND SAFETY
�3..CK-9��-�04-.CpQ AETNA
QcyNo. Compony
BWL�ING
Certified copy is hereby furnished. FpR APPLICANT TO Flll IN ADDRE55
� Certified copy ia filed with the co�nty buildinp inspec- BUItDING
tiondepartme��. AD�RE55 24241 S E D iocnuTY
NEAREST
oo+e����84 appUcanr THR QN�RN r,unpp arv D ND BAR tia ckosssr.
CERTIFIGATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. A55E55oR
COMPENSATION INSURANCf SRE OF lOT NOW ON LOT NWV BOOK �AGE PARCEI
(Thia sec(ion need nor be compleFed if the permit a for one USE ZONE MAP
hundred dol lors(;t00)w less.) T2nR 3 3 0 2� s�ocK ior wo. nm. /�.��
h� SPEG0.i }
I ceAl fhaf in Ihe performance of Ihe w«k for which ihis OWNER 1'[-[ Na — CON�ITIDNS h-
permi�s iuued,1 shall nat empby ony perwn in any monner DISTRICT GROU7 CON ZON PROCESSED BY �
so as to become subjact ro the workers'Compansolion Laws. �DRESS �.0 7 4 P1�12 K I EW D R, �Q �� �f � �
Y
Pole Applicapt � CITV C OV I N z�r O
ARCHl7EC7 OR.. � '�.:7EL. STATISTICAL C1A551FIfATION APi. CONDO. u
NOTI�E TO APPIICANT: If,.ahsr r'wking thla�Cartificate�of � �- ' .�p� 'f'�
m EN iNfER:.�� D CtkSS NO. � bWELL..kJNrtS_ a
� xemption, �you should becoma�zubjecr to the�Wakers' � , � � � � � �
.:ompenwtion provisiont of ihe La6or Code;you must forth- �qppRpu.3 SeWER Mnv �
with wmply with such provisions or this pumit xF1o11 be . � TE�� Z
deemed revoked. CppiiRqRpR gK. pG, VAIIDATfON
UCENSED CONTRACTORS DECL4RATION �LiC
I hereby affirm fhat I am Rcenaed under provisiona of Chapter 9 A�DRE55 NO. VALtiATION �
(canmencing with Saction 700D}of Divuion 3 of 1F�e�8wineas and UC.
. Profeuicns Code,ard my license is iw futl torce ard sffecG ptt �V,55 a 64,,8 5 0 . ►
3 715 8 Q 3C7.FT. NO.OF ND.OF CHEIX
LicBnb Numbar tic.GI�• � SIIE 15 0 Q STORIES 1 FAMILIES ONE
E
�,,,�„�,,,TH& ANDEN GRO[I��@ 1,�23�84 DESC(RIPRTION50iWORK C T NEW a
� OF SINGLE. M LY H ME �� �
I om exempt undor Sec. aiTER FINAL
B.BP.C.fw thii reawn ��R � DATE � 1�(g
USE OF � FINAL �1 5 2 2 A.
DaN: E%ISTING BLDG. �EM�I
Signplure APPIICANT TEI. � ��' #� � ��L�
OWNER-BUILDER DEQARATIQN ��M NO.
1 herr.by affirm that 1 am��emp�hom Ihe Conmocior'a Liceme ADDkE55 10 74 P A R K V I E W DR. C � � �2��� 3
law for tha following roason�Sec�ion 7W1.5,Busineas and
P,ofasaions Code): pRE • •L c��'J�
^ - BUIIDING
� J 1, as owner of the praparry, or my employees with qpDRE55 �2,� 3—�S�l
wayes as rbelr sole compensarion,will do Me work and !
'� ihe afructure is nof inlendad or offered for wle(Section ����TY �,
70M,8usinau ond Professions Code). MOVING TEL. �I
� I,as owner of fhe �o e y coniraciing NTRAROR NO.
p p rry,am exclusivel f 1 5 2 3 A
with licensed conM1actorc to conahucf Ihe projecl(Sac- A�R�
tion 7014,8usiness and Rofeuions Code). �� �� � ��
REqU1RE� TOTAI 5E(HP.CK fROM E7(IST.
CONSTRUCTION LENDING AGENCY �T gq�K YARD HWY pR�p��N WIOTH ,
I heieby offirm that there fa a consfrucfion lending ayency fa FRONT � •3 8 5�5 Q
the performanca of th�work fw which this permit is iss�ad P.t. � S��
�Sec.3047.Civ.C.). � � SIDE t/ �S� . • •.�..�J�.�J O c=.�
f P.l. J
lander's Wme � �z,� 3'�$4
� Lander's Address V.C.Fee t :j- verm�t Fee .�7.��
,�, 1 certify�Fwt t hav�r�cd this application and state thot the iuunnce Fee /O•�+�
� nbove infamarion is conoc�.I ogree to comply with.all Counry in�ese�gwwo Fae s
ordimncw and Slaw lavw ralating 10 boildiny conahuction, � Towl Fee .���7'3 d
� nnd heroby oulhori: eprss�ntotivoa of 1hii.Counfy M enter
u e ubovo-m � ned any for i�spection purposas.
� � SFE REVERSE FO[EX►IANATORY IANGUAGE
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