HomeMy WebLinkAbout1661A 1662A (9) ,
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WORKERS'COMPENSATION DECLARATION ''�' ' ' �� � � '� � �� �
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1 hereby oHiim that I hove o certifim�e of�o�s����o=P�� �--� -�� ��-- � 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��ompni3mdus� T��amntr;.Co. ,
OBU�IDING A />c ,
Cenitied copy�s hr.�eby fomished. FOR APPLICANT TO FILL IN ADD4ESS o�, ���%
� Certified copy is Filed wi � h counf buildin in BURD'NG � 1 n
' ro�dcA rtmenf. �DC4ES5 241i 11 St. Ives Ct. J=I-J
9ot Appiicont � � CITV ��Ra zio iov+uTr ' � -
ERTIFIC TE OF EXEMPTION FROM RKERS' � ' -� '- ��' NO.Ov BlDGS. • niFARESi-.. '
COMPEP75A710N INSURANC ` SIZE OF LOi NOW ON lOT CRO55 ST.
(This seclion need not be completr.d if fhe permif is for one TRACi (7 RtOCK LOT . 13 MAP BOO�C � PAGE vARCEI
h�ndred dolla�s(S1Q0)or less.) .
o:vnaRCalif.�Communities IncN'E� —3700. u ZONE Maa .
I teNify thal in the perlormance af Ihe work lar which thi3 �f 1� ��A` , � !_ . a I
permi�is issved,I shnll nc�employ any pnrson in ony mannr.r ADDRE5531 H� A�A1T'W 1 Avenue � ^ . _l
so os io become s�bjr.cr�o ihe Workers'Compensafion Lnws. �'Y� CONDITiONS u
. . . . CITV , .. ZIP 6 .. . . . ._ , . . _.. �
Da�e Applicunt ARCHI7ER OR TE. p!S1RICi. G40UP 7YfE ��RE I'ROCESSED BY.._ � I
'17ICE TO APPLICANT: �f, of�ei mokin �his Cer�ltico�e o( iit11R Hassenian 2-1864 �pN�STJ. ZOh: �V
�nplion, you should become subje�Ct to Ihe Workers' � �� �NGiNtER N0� / .r u
wmpenza�ion provisions af ihe labot Cndc,yoo must fortfi- �ppRE5S39gO �aCSCCY'1' Pl. iE1���N.B.� 9266 I�� ��J ,�{ � � � �d
w�nc �omply wlih such provisions or ihis permi� shatl be TFL. SiAf15TICAL CUSSIFICATIOU AP�. CGNDO. N
deemed revoked. ' � . CONiRAROR NO. . - . . Z
LICENSEDCONTRACTORSDECLARATION �' � ���'393�01 ClA5SN0. �wELLUNITS
I hereby affirm ihoi 1 om licensed uader pro•is�ons o(Chap�er 9 n0ot+[55 NO. .
� (commencing with Set�ion 7000)of Division 9 oF�Fr.�osiness and SEVVER�MP
... ... ... . . LIC. .. .
Professians Codn,and my hce�se is in full force and effeU. i C�qSS B1 � gK �� • VALIDATION -' .
. i. NO.OF . Np.OF C11FCK � ' .
li[ens�Num6er LiC.CIa55 STORIES FA1l,IL!ES CNE ' ' �, '
vuuanoN
� 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 • �2�
0.8P.C.f r Ih reaSon REPAIR �
c c
U_E O
c: � Ew5T7NG BIDG. CEh!OL ❑ � I •ti�'2.��J..
Signalure A�MICANT fFt. FINAL
mawT> No662-3700 -9���r&' . .!;'�.��.j?; •
d. ' R-HU DER ECLARATION �DATE — � �- �� �
Ihercbyaffirmihailamr.o.mplfromtheContratlor'sLitense 31H�e� i�1TW1y t�VC.� C..�`t.� 92626 ::. . . � �.` �
low for Ihe follawing tca n(SeU�oo 7071.5,Bus�ness and /�DeE55 FINAL h � �Q Q,,. �� _
ProfesSionsCode): � � �� ���� � PREoENt �Y� �/l.�Gt.�.. �
� 6URD�NG � .
I, as ownr.� of ihe properfy, or my r.mployees wilh nDDR:55
, woges os iheir solc cnmprtnannon,w�ll do rha work end
� �he stioctvrc i:not Iniended cr o1(ered tor wt�(Section �«a�ii� ' . , .
7044,Businr.ss ond Professio�s Code). � � � A'.OV�NG -' � ' ' '�--�� TE�� - ' � � � . � _� J�C ii
� � �,ns owner o(�he propr.rly,am c�clusively[Onlro[ting fONTRACTOR NO. _ '•^ '
�with Ilcensed conrracrors ro construct the projec�(Sec- qooar55 '� ' :.'• e"n : . � "
lion 7044,Business and Pro(essions Codc). �
� CONSTRUCTION IENDING AGENCY � SEi�nCK 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 iss�ed P L - '° •'>>'�C'U�,
.... . ... .. . . . . . .
(Sec.3097.Civ.C.). . . P.LE . O``!r�'V�
Lender's Nomr. � v�
{� l0.'.1A Rd.N
. . _. . . P.[.fce S ����. . Pn.mit Fen u I�'�� . .
Lender's Address �7 ',�` '
1 certily thot I have thit applito�ion and stote thal�he . ._ ��+�' /,��'(� . Inunncn Pee ld'� LD.MA PIC M '�� �� ,
abpve informatio �s correc.I agree to comply wilh all Counly Invesi�qo�ion Fee �j ,
prdin nces and tale� Iming to building conslruction. . .. . �--� Totol Fee -O°��� �� LD!lA Pe�m.M � � � � �
and h eby oui ize this Co�n�y ro en�er � • .
n�h.oi v .rioned opert for in petti porp ses. y���� . . ' � .
. `� � .
- ' � n SFE NFVERSE FOR EXPLANA70RY LANGUAGE � � � • �-'" �
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