HomeMy WebLinkAbout1657A 1658A (9) . . . . .._. ... _ _ ... _.. . . ... ._... ..._.. ... . . 7
VlORKERS'CO�l,FENSATION DECLAR/�TION ' ' , ' � � • I`--
I hr.reby nfiirm ihal I hnvr.n ceriificotc of�o�=e�,,v,��, �� � � ��APPLICATION FQR BUILDING PERMIT�� -- ��1,
ins�rr.,er a cert�licare oi Workeri Compensa�ion Insurance,
or a cc�t�ficd copy ihcrcof�Sr.c.3800,Lob.C.) � COUNTY OF LOS ANGELES BUILDING AND SAFETY .
PolicyNo.�C u60-75�6m���ncius Indennitv Co.
Certified co is hereb furnishr.d. AD�DRE55 �`F'Y 3 ' "�Pi C.iti,,
` ❑' P1' Y FOR APPLICANT TO FILL IN O
� CPrtiFir.d copy is filed wil th.tou �y b ' ;.nf �- BURDiNG 24405 St. Ives �'.C. .
ti n departmenr. �� ADO4E55 � �j
oto_.. �J�_.y��r . . - .. . �
_C��Applicent -q— CITV Dianond Rar 21P " LO[ALITY
RTIFI ATE OF EXEMPTION ROM RKER$'� ' ' ' � NO.OF BIDGS. � NEA4EST . ... . _. . ._ .. _ . .. ... .
COMPENSATION INSURANCE . SIZE OF LOi NOv!ON lOT CROSS ST...
(This setfion nced nol br,compleled if thr. 'rmit i5 for onC ' " TRACT 4ZSGE7�� � - 1Z ' ASSE5504 ,, ' .
h�ndred dollors�5100)or Icss.) ��aK MAP AOOC� � PAGE PARCCL
' EL Uc Qry: �fA?
I certify tha�in the�performance of ihe work ior which this � CS IT1C no662-3700� �,�� � ��� ;}
permil is issued,I sholl nol employ any person in any manner 3187.A Airwa Avenue eZDDOt7 S��CiAI"�� �� � � C. I
So as lo bC[ame SubjeCt to 7he Wo�ke�s'COmpenSa�iDn Laws. AD�RESS' Y ' ' COhDITIONS Q
� u
Daie Appliconl. . � . CiTY Costa Mesn. . zia ,92626 . . ._ . ... -. . . - . . �.�
ARCHrtFCT CR 7EL. O
NOTICE TO APPLICANT: If, oFler moking ihis Cerli(icale of . UISiRiCT GROUa TYPE.. FIRE FNOCESSEU BY
FNGINEER a Cft�a7R 714r,o.752-1864 �� I
. �np�lon, you should bemme subjetl ro �he. Workcrs' ' CON�Y�� Z �j
.naensaiion provisions of the labor Code,you must lorih• ncc�[5399� westerly Pl. 'E170 N.B. 92660 !� �� � � a
with comply with such provisions or this pe�mi� shall be � TE� � vi
deemed rr,voked. �ONTRnCT02 SAME AS OSdNER ND STATISTIfAL CL455!FICATIOY , � AP�. CONDO. Z
LICENSED CONTRACTORS CECLARATION��� �. . . ... . . _._. . ��� �CLnSS NO. � Dv,'etL.UNrtS� � �
I hereby o(firm�hoi I om litensed under provisions of Chap�er 9 nD�a[55 r,o. 393701
(commenc�ng wfih Sr.c��on 7000)of Division 3 of ehe 8�siness and . .. . ,.. .. . . . ��� SEWER MAa �
Proiessions Codr.,and my license is in full force ond effetL d1Y C1A55 B 1 " ' -' - �
� . , eK. �. VAIIDATION
5�,{SF ] NO.OF Np.OF 1 CHECK
�L�cense Nomber 993701 Lic.Class A Sf�Il Y sTea�es 2 FAMILIES o�.=_ ' ;,•1 f;'S 7�
�: /�{� .� _ . . ._.. .. NEW yF, VALUATION . .. .
�Contracio <<r DfSCRIPTICN CF Y.'tl7K L:J
��• D'atc ADD � S ZO2�900.OO i: • • • •2�
��om C.empt under Sec. " ' �� ALTER � , � �::i'Q 7� '
% B.BP.0(or I 's reason S.P.D. — PLAN 4 REPAIR � 's ' �� � �" � " �i)��1�5 r J J
l � D e: 1 USE OF D�MOL n
FXISTiNG RLDG. ❑ .. . .... �r,y,� e
� Signature ACf'LICp.NT /,TEL. r 7'.V J�'c,6..
V ER�� �ER DECLARATION �1 662-3700 FINAL
. . IF2:NT1 �:JO. . DATE �..Z.Q�S7 .._ ., .. .. . ..._
� Iherebyaffirm�ha�lame' mptlromiheCon�ractor'sL�cense ADCRE5531H7A A�YW:.t Ave. C.i•i 92626 � � ��
Law lo�thc followin9 reason(Sec�ian 7031.5,Business and � '� FINAL ' � � '
Prcfessions Codej:._ . . . . ."'- .. . .. ppt N . By . .- - -. .. . _
BUILDIhG
I, as ownr.r ef Ihc propeny, or my employces with nCDR�SS ' � ��� C'r.:7„�
. ; � �n�ages oz fheir sole compensat�on,wi�l do�hc wo�k and ��`T� � ' '" � " �
� .i the s�r�cture is nof imended or oHernd for sole(Seu�on , � ' " • • • • 1 .
- 70ed,B�siness and Professions Codc). u,Ov:�G ' �� - �tEt. - _ , - � �
.� I,os owner of Ihe properly,am exclusively tonlraclin� CON7RA�TCR NO. 1 ' . __ ..)�o y�!C�.1
' "'. .
wi�h licensed coniractors 10 conslruct ihe project(Sec- � qDDRF55 ,
lion 70A4,Business and Profrs�ions Cade). y „^��`�,�`
REOUIRED.. 1(7IAL SEI3ACK fltiiM %�i. � �
CONSTRUCTION LENDING AGENCY ' ' - SEI BnCK vARD HWV' pkpp,�INE wiOrH � � 'V;� r_
1 hereby offirm Ihot lhrre is o tonslruclion lending a�ency for ,H�N, ' .' .0.; II 6
�he perfa�monce of the work for which�his permil is issucd - P.�. ���� � ��� � . - � .� -. � . .. . . . .- - .
(Set.�097.Civ.C.). SIDE �
. .. . . P.L. ' ''' "" '
lender's Name
� ,S� LDMA Rrtf.p '
Lender's Address ' � P.C.fec S��Q�a a � vcrm�t Frn��- �-
' I tenify that I ha d ihis application and stnle thof the . �� � ..��F� iesua�re Fee -���� LDMA P/C M � , ��� .
obov informa' n is corre I agree to comply wilh all County ����s��ga+�on Fee. .p��. •,.
rdino ces n SIo •ows c 'ng to buildin�cans4uction, ,, . . . _ -- To�ol Fee � O V l/ �D.`l,A Ve�m.N
he by uth ze r a, �t��his Coan y io enfer � � � ' � �
u o 1 6 vn- e �one propr,r for�hspecrior p�rpos s. 1�/ � � .
_.._.
� .._ . . . .. ... . � '��NJ . . ...... ._ . . ... ..� -� .
� � ..
� Q SFE REVFRSE FOR F7IPLANATORY LANGUAGE ., •
�" Si�na�ur 101 A plicont or Aqml pa•� . . .. ........ .... ... " ' ' ' '' . - .
. . . . . .. .. .. 7i
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