HomeMy WebLinkAbout1661A 1662A ,
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WORKERS'COMPENSATION DECLARATION ''�' ' � �� � � '� � �� �
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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 � � � � ��'" �
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