HomeMy WebLinkAbout1671A 1672A (10) , . . ....... . . ....._ ..-----. _. . . _ . .... .. . .... . . _.. _ ........ ..._ . .. ._.
WORKERS'COMPENSATION DECLARATION = �' ' ''. ' '. � � �'. ���• � z
1 hcreby a}��rm that I havr,o cn.rlifimlr.o,�a�,e��,o s��f ��� �� ���--�APPLICATION� FOR .BUILDING� PERMIT �
ins�rr.,or a tertificorr,of V�or4crs'Compensatian Insuronce,
or a ce.�uf�ed copy ihe�eo((Sec.3800,lob.C.) : COUNiY OF LOS ANGELES BUILDING AND SAFETY �
PolicyNo.��$b�Z15F,mPaEfl�1��s Tnd�r.mi ry Co -- n�n
� Certified copy is hcreby Furnished. FOR APPLICANT TO FILL IN ADORESS � �l O W�� 4Ti . ,
� cr�i{ied copY is filed wilh t cou ty 6uil ' nspt.- OUI�DING ' �
+o�c!� rlmenl. ADDRFSS 24410 St. Ives Ct. $.
Da1e ApplicoN � '��' CITY ZiP LOUIITY
. " _ 'NO.OF BlDGS. -. . NEARESi....__... .. ._ . . _ ... . .:
' C RiIFI TE OF EXEMPTION FROM W KERS' � S¢E OF tOT NOIY ON LOT �R055 ST. . �'//[i(y�(/!(�-y�f
� COMGENSATION INSURANCE •�
(This seciion need not br,completed i(�he permit is for one � � � runct� 4Q566 BLOCK ��Q7� � 28"� ASSESSOR �- � � �
hundred dollors(5100)or less.) �MP AOOK PAGE PARCEL
•[. U.5�Z N NWP ''/�
O�VfJ F� � � '�-NO I
I cerfify thot in Ih?perfermonce of'1he work for which this — /'C /� �� '✓^`I' !-
permit�s issucd,I sholl not employ any pr.rson in any manner . �DCRE55 318� f� ��lIW1 AVCi1llC'� -�� � /�� �'ECIAI � - a
so as�o becomr,subjec�to ihe Workers'Compensoiion Lows. y OWOOQ COhDITIONS 0
Dote � Applican} � � � CIiY Costa P'IL'S3 - ZiP 92626 .. � � � '. � " � ' - �
TICE TO nPPLICANT: If, afler makinp Ihis Cerlificalc of ����I`ECTOR T«� _ �iSiRICT GROUP TYFE . FI4E PkOCES5ED8Y � I
ENG�N.FR crninn 71 ti�.
mpiion,'you should become subjett fo thc Workers' �--� /� n CONS • �hE W
,, mpe�sarion pro�is�ons of rhr.labor Codc,yo�m�s�ro�+h- A��aes3990 1dEstcrly Pl �%170� N.B. 92660 /�-} y
iih comply with such provisions or �h�s pe�mil shall bo �� TE� � � �
$TAfISiICAL CLASSlit��iC�AT10N .�{—/ ACT, �ON�p. 7
daCmCd revoked. . ,� � �� � � CONTRACTCR r N�� � V� Dx'ELL.UNITSJ_L_
LICENSED CONTRACIORS�ECIARATION � . � � � � -� p�, �� � QA55 NO.
I hereby affirm tha�I om I�censed under provisions of Chaprer 9 nDCaESS n10.
(commencing wiih Section 7000)oF Division 9 af Ihe.D�siness and . . ._ . . . .. . ��� .. SEV�R�MP
Professions Code,and my lirense is in full forcc and r.firci. CiTV CLASS B1 �K �' ��� . " VAIIDATION �
� � $ . 1 NO.OF NO.OF._ CHFCK '
licensc Numb r l�c.Cfoss � 5 SiORiCS �Z � inM.iLES 1 OnE . . �
VAIUATION •
��r�c� ��, pa�„ f OESCRIPfIONCF VJpRK'-- App � S 16 900 0 , �� �],� �
I am exempt under Sec. - �
, A�TER �
6.&P.C.( r is re so _ O = . . ,.. „ e • s •�;�
' ... REPAIR
� - � USE OF � I •C I: �.I`�
�" EXISTiN^v BLDG. DEMCL _.
- $ignol — -- A�RiCANf TEL � r.
1+ R- �E RATION IPR;HiI �L�Wcf62-3�00 FINAL . . .e_._"(;.�'.�_i. ..
� I hereby affirm that I om empt from the Contraclor's License -DATE=-�S ZZ—,�7
Law(or�he following re n(Sec�ian 7031.5,Dusiness and �oDaES A v AV2 C.it. 92626 FINAL :`'��lJ�t.'�v .
- Profcssions Code): . . . . .. .._._.. '. NkE_tn� SY ' � �
� BUiID'hG . - . . . .
I, as owner of ihe property, or my employer.s wiih nooaE55
... .. .:�,�
wag=s as iheir sole cornpensa!i�n,will do thc work and
� �he struc�ure is no�infended or offr.red for sale(Sntlion ����T� . ` ' ' �
� � �7044,Business and Profr.ssians Code�. - MOVING " "' - TFL" �" " ��" � "�`� �7'�!�� � ;
CONTRACTOR NO.
� I,as owner oi the property,am eKclusively conMatting � �. � � . , • � ,
with licr.nsed contracfors ro construcl the pro�ec�(Seo- � AD�RESS ` �
�ion 7044,8usinr.ss ond Prafessions Code�. ' � ' I ^ /::,"),�/V
RCCUIRED iOfA�Sel[fACr, rc '.1 %��I. ` • ... . . . . ..
"' ' CONSTRUCTION IENDING AGENCY- ��"�" 5Ei enCK YARD �nvv CROP.IINE V11DIH � � �
I hereby affirm Ihot there is n cons�ruction Iending n�r.ncy for iltUNl �� • ��� _ ^ � 1;.,';,�V;j�
�he pe.(o.mance ol ihe work for which ihi�perm�t is iss�ed -�-��- P� � � � �� � �� �� � � � � �' ��
(Sec.3097,C�v.C.). SiDE - � G C G���—J�;
. ,
.., . . '•' ..
. . . ... . . . .. . _ . P.L . .
.. .. . . .... ... ,. ._: . _ . . . . ... ._.
lender's Name ...• •
IDf.N Re1.p � . ' .
lender's Address ��� � � P.[.Fce S� � +�7 PC�TiI FP!! �.�� �
. I cerlily lhat I have read this application and state Ihol fhe ._. ,�,� .7�.�- �� Iseva��e Fee i�r`S� LDMA P/C M-� ,�'
. _.
obave informnlion' orr. .t og�ee lo comply with oll County I�.enr�g�r�on Fnc (� , ' '
ordi nt�s and S atq I oting to building construUian, - Toiai Fea-� Vr������ lCY�A Pnrm.N ��
�Q .._ . .._ _..
�.a d hc�(eby auth eprr.s n����;-�_y"of this C unty to enler ' � . ,- �
n hl;o ov entioned opaily f'nr inspecl n pu oses. � ' ' t �
cY��-s,�`�a,�
-- SEE REVERSE FOR EXPUNATORY LANGUAGE . ' . � .� ,. � �
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