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HomeMy WebLinkAbout1661A 1662A , . � -- - . .... ._ . ._.._.. . . . --- ... _ ._. . _ . ._. . � WORKERS'COMPENSATION DECLARATION ''�' ' � �� � � '� � �� � . . .. .� .. . " , ' 1 hereby oHiim that I hove o certifim�e of�o�s����0 SP�� �--� -�� ��-- � APPLICATION�� F�OR.BUILDING�� PERMIT ��-��� � insvre,or a cerrificaie of V�orkers'Compensatian Insurance, . , or a cerrified copy�hereo((Sec.�800,lab.C.) � COUNTY OF LOS ANGELES BU1lDING AND SAFETY ColicyNo�$,(�Q]S�ompni�Ryays� T^.la+�+n�tr,CO. . � Cenified copy is hr.�eby fumished. FOR APPLICANT TO FILL IN noo4E5s � �� . � Certified copy is Filed wi � h counf buildin in BURD'NG � 1 � t�on dcp rlmenl. ' �DC4E55 24[i11 St. Ives Ct. � J=� 9ot Appliconl � " CI7Y � Zi� lOG4LITY . . ERTIFIC TE OF EXEMPTION FROM RKERS' � ' -� '- ��' NO.Ov BlDGS. - � niEARESi-.. ' COMPE1�75ATION INSURANC ` SIZE OF LOi NOW ON LOT CRO55 ST. (This seclion need not be complelr.d if the permit is for one TRACi (7 RLOCK LOT . 13 MAP BOOC � PAGE vARCEI hundred dolla�s(5100)or lest.) . o:vnaRCalif.�Communities IncN'E� —3700. u ZONE Maa . I ceNify tha�in the performance af�he work�far which this �}�l� ��A` , � _ . a I permi�is issved,I shnll nc�employ any pnrson in ony mannr.r ADDRE5531 H7 A'AlY'W 1 Avenue � ^ . _l so os io become s�bjr.ct�o ihe Workers'Compensafion Lnws. �'Y� CONDITiONS v . . . . CITV , .. ZIP 6 .. . . . ._ , , . _.. � Da�e Applicont ARCHRECT OR TE. p!S1RIC7. G4UUp 7YPE �iRE VROCESSED BY.._ � I '1710E TO AP%ICANT: IF, of�ei mokin ihis Cer��fico�e oi i1t11R Bassenian 2-1864 �pNST. 20h: �V �nplion, you should become subje�Ct to Ihe Workers' � �� �NGiNtER N0� / u �ompenza�ion provisions of ihe labor Cadc,yoo must fortb- np^aE5S39gO SaCStCi'1' Pl. iF1���T7.B.� 9266 /0� ��j � � � � �d w�nc �omply wlih such provisions or ihis perm�� shatl be TFL. SiAf15TICAL CUSSIFICATIOU AP�. CGNDO. N deemnd re�oked. ' � �pNiRnR04 NO. . - . . Z LICENSEDCONTRACTORSDECLARATION �' -� ��� � � ���'393�01 [lA5SN0. DwELLUNITS I hereby affirm ihoi I om licensed u�der pro•isions of Chap�er 9 n0ot+[55 NO. �`�R'�P , � (cOmmentinA with Setlion 7000)of DivisiaR 9 oF Ihr,6usiness and . .. ... ... . . . .. . LIC. Professions Codn,and my lite�sc is in full force and effetl. i CLn55 B1 ' gK �pG ' VAIIDATION -' . . i. NO.OF . Np.OF C11FCK � ' . licens�Number LiC.CIa55 STORIES FAII,IL!ES CNE ' ' �, ' vuunno►+ � CFSCRI7TION OF WORK ' - ' ". . NEW � ].9Z�900.OO � J Confroclo Date ADO � f �I om e.empt vnder Sec.` S.1'.D. — Plan 3�� ��T�R � , `1, ��, F � . f .. .. .. . . . . t�• e • �L� B.BP.C.f r�h reason REPAIR � c c U_E O c: � EwST:NG BIDG. CE1:OL ❑ � I •ti�2.l�i J.. Signalure A�MIG4NT fFt. FINAL maiuT� No662-3700 -9���r&' ' '!;',��`�� • d. 'R-BU DER ECLARATION �DATE — � �- �� � Ihercb affirm�ha�lamr.o.m �fromtheContrac�or'sl�<ense � 3187e'� i�1TW3 t'�VC.� C..�`t.� 92626 .:. . � � bw for Ihe folbwing tea n(SeU�oo 7011.5,Bus�ness and /�DeE55 y FINAL �,' / � G�!,O�`F� Profe55ionSCode): � '� ���� � PHEoENt �Y /1,.�l�.. � 6URD�NG � . I,as ownr.r oi�fie praperty, or my r.mployees wilh nDDR:55 , woges os iheir solc cnmprtnannon,w�ll do rhe work end � �he strovorc is not Iniended cr olfered tor sat�(Section IOCn�ii� ' . . 7044,Businr,ss ond Professio�s Code). � � � A'.OV�NG -' � ' ' '�--�� TE�� - ' � � � . � _� J���� � � � �,ns ownCr o(Ihe prOpr.rly,am c�clusively[Onlro[ting fONTRACTOR NO. _ '•^ ' �with Ilcensed conrraclors lo const�uct the projecl($ec- qD�RF55 �� ' ;'• e"n a • � " lion 7044,Business and Professions Codc). � � CONSTRUCTION IENDING AGENCY � SEi onCK YARD I�wY tV�ApWpP��nEf ���� WIDiM � °���O r � ' I here.by af(irm thof therr is a construclion Ir.nding a�ency for f uUNi the performance oF the wo�k(or which ihis permit is issoed P L - '° •'>>'�C'U�. .... . ... .. . . . . . . (Se[.3097.Civ.C.). . . P.LE . O`,�!��'�� Lender's Nomr. � v� n 10:1A Ref.N . . _. . . P.[.fce S ����5� � Pn.mn Fen �3 II'�� . . Lender's Address �7 ',�` ' 1 certify thoi I have thii appiito�ion and slote thal the . ._ �'+f�' /,��'U . b�unncn Pee ld'� LD.MA PIC M '�� �� , above informatio �s correc.I agree to comply wiih all Couniy invPsi�qoi�on Fee G . o•din nces and ro�e� Iming�o building construdion. . .. . .--. Tmol Fee ..O°��r �� �D!7A Perm.M . . . . . and h eby oui ize this Co�my ro en�er � • . n�h,oi v .rioned oPert for in petti porp ses. . . . .. ...._. . . .. . y���� . _ .. . . ... � . . f/ � . - ' � n SFE NFVERSE FOR EXPLANA70RY LANGUAGE � � � � ��'" � S�qnnru of A Ilcvm or A7en� —.Da,e . . . .._. ' ' __.._. .. .. ... ... . , ... . . : .�' ..:�i I a _ .....1 0 0 � . _ ,`- -- ' .T n C r''C ' �Q O n p' ^ � N t.G O� C- v s �� . • o ° �9 n� � ,p v 0 � � p . � �r O n p �^ � � v � 'o � .r+ N O �O �,�, p �_• (l C p 3 G O ..,i p m o � � � Q v � 3 � � r P �. 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