HomeMy WebLinkAbout1651A 1652A (9) . . _.. -- ... .--�---.__.._... .._ ._... .._.... _ .. .... _ _ ___ _... . . ... . .. .. .. ..........
WORKERS'COMPENSATION DEClARA110N ��' '� '•'�� �;"� ' ' ' . L
1 hcrr.byht�irm that I havn a tcrtificate of�e�5��„o,P�� --�- �� � . �APPLICATION��F.OR BU.ILDING� PERMIT� - �
ins�re,or o carf�l�cate of lVorkeri CompPnso��on Ins�ronce, �
or a cr.ri�fied mpy thereof�Sec.3800,lob.C.) ' � " ' �� � � � �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo.RC R60-75$(PnpaT�tLd7�c Indemnir,y Co "
� Ce�iilied copy is hereby furnished. FOR APPLICANT TO FILL IN nooeF55 ���v�/ � • � •
� Cenified copy is filed wirh r,coun y bu� ' eunD:NG
�de rtment. ADDRC55 24402 St. Ives Ct. ,nj.
Dale��Applican — CITY ' ZIP ' LOCALITY . ..
C TIFI TE OF E%EM,PTIO FROM W f�KEBS' � � " -� � ����NO.CP BtDGS. -- -� � taEAaEST--,.... /► •
� � CO.VIFENSATION INSURANCE
SIZE OF LOT NOW ON lOi CRO55 ST. !/��✓(1*G�C.��
(This section�need not be completed ii the permit is for one - -�-- -- --� -� n55E550R ,. ,
hundred dollors($100)or less.) , , TRAC7 42566 QIOCK i h' . 2� MA7 AOOK PAGE PARCEL
USE ZONE �+`A� O
I cenify that in�he perfo�mance of ihe work for which this �N'h .� � � N� — ��1, �� /�r�'� / } i
pr�mif is iSsued,I Sholl nol emp�oy any p?rson in ony monner . pCDRESS �.31H� A A1T�13 Avenue ��� .. � SPECIAL d
so as io become subject to ihe Workers'Compensoiion Laws. �n° � COhDITIONS 'u
Date � ' APplicom. CITY t .. z�a--92626 �. . . . . . . .. m
TICE�TO APPLICANT: If, afier moking Ihis Certifitate oi ARCHiTECT 04 TEL. , DiSiRiC7 G¢OUv TYFE Fi4F PROCESSED BY . F� I
i �•q . FNG!NFFR � — CONST. 7 y
mption, you should become subject �o'the Workers' l W
..om�-�zar�oo P�o��s�o�s of inc i�6o�coaP,yoo�:,�:r rc��!,- nooRes3990 Westerl Pl i�170, N.B. 92660� �C� �-3 �. ..?'`� �a
ith COmply wi�h Suth pr0�i5i0n5 0� 1hi5 permit sholl be 7[�, STATISTICAL CIASSIFICATION APT. CON�O. ,'Z
dECmCtI roVOkCCI., � � •. • [ONTRACTOR T. � NO. �t�� . ... ..
IICENSED CONTRACTORS DECLARATION � �� � � ���, � - QA55 NO. v `� D'hTLI.UNITS
I hereby afti�m�hat I am licensed undcr provisions oi Chapter 9 ADC2E55 NO. �µ�R�P
(cemmencing with Scction 7000)of Division 3 of ihe B�s�ness ond .. . .. .�i�. . .. '
Pra(essions Code,ond my license is in full force and effect. CiTY C�n55 B 1 eK � ���� � " VA[IOATION
� _ 5 .__Z NO.O� NO.OF CNFCK '
LicensaNvmber � � 79�7(11LicClass � � 5 STC4IE5 Fn1TiUE5 1 ON`- , � � .�`.I b�� T1
/�� � �� � .VALUATION. . Y . • • .2 1
Contmct&ti �- Dale �� DESCRiPTICN OF WORK A p � S 2 2 OO OO
�I am exemp�under Sec. � �- � , � � •Ci�i Q ll�.
' SPD PLAN 4 A�TER (� T
6.8P.C.(011 -5 fea50n . . . — REPAIR � � s � �� � � ^ '.r�.\;C�-U:i '
. . ..-- D e: ' USE OF prfl0l
EXISTING BIDG. � ����' � i�G.�� �(�
$ignUture � nP�PRI T) 711wi562-3700 FIN14L • '
NfvER-B �DE DECLARATION �ATE� r�ZZ^S�� �--�� �� � �- � -�
• 1 hereb affirm tha�I am empt from the Conirocror's licensc
� Law for�hc iollowinc�rrta on�Sr.dien 7031.5, Businr.ss and ADDRESS ](+ A W3 t�VC. C.Pf. 9262G FINAL � " ��' ' ' " ; �' ' ' ' �
�Professions Code): � �- � � �� " � � reestNi 0Y �L.r�� ���
� BUILD�NG
I, os owner of Ihr, properly, ar my employces with ADDRESS
/ wages as thcir sole compenso�ion,will do ihe work ond ���in, , .� '� _ . :'1 6 a 2 ll
�he shucWre is not intr,nded o�oIlered(or sole(Sr.c�ion
' 7044,Buslnnss and Prafessions Code). � � � � N�OVING " � ' ' TFL• „'.� , ' . 1
� I,as owner ol ihe proper�y,am e.clusively conrroc�ing CONTRACTOR . . NO. . . . . '_ ...,..._...__._.`j; • • e . �
wl�h Ikensed conimc�ors to con:truct the pro�ec�(Seo- qpDRESS . . I •��2.O Q '
fion 70<4,Business and Pro�essions Code). .,
R(()U�R:U IUTAI StI3ACK r u`.1 . . �'� � . - .
CONSTRUCTION LENDING AGENCY � SET BaCK YAR� HWY FROP.LINE �'/,DTH _ • a K'��"r`
I here6y af(irm�hat ihere is a mnstruc�ion lending agenty for tgCN� . , r.- ������'
ihe perfo.monce of the work For which this permit is issued - � a l. - � '' � u�,����5
(Set.3097,Civ.C.). SIDE '- .
� . . . .. .. P.L. . ...- ». ... . . . .. . .
Lender's Nomc p� .�T1 � � •
' ' ' P.C.FPP S SOD� Pnrmi�Foe... p �.��v- LDMA Ref.M ... . . . . ..
Lender's Addrr,ss
, ..I ceriily�hal I hove , is opplitniion and staie�ha�ihr. _ �.[ ,fj' �- �? - is,u�.,ca Fee �v'���� �DMa a/L y � , � � � ,,
o6ova informmio �s correa. gree�o comply wiih all Counry Invesiigm�on Fex g[- '\ .
O�di nces nd lol . ws rel T�k g fo 6uilding[onstruttion, . .. �-� - Toiol Fee -�� p V�a•v V l�MA Verm.N--
o h� .6y uih zef.a se aiiv2�s,oi this Coi nly fo c ter . ' �
p n t .ab ve- Rf o ed p pe ty for inspecti �purpo es. �{�� � . � . . �
� � � , ;�f� SEE REVERSE FOR EXPLANATORY IANG�GE "� ��� � . � - .
Signa�urr f Applicanr or Agrm � Do�n' ' . . . .. .. ...' - '. . ... .. . . .. _ . � . .- . � Q�
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