HomeMy WebLinkAbout1653A 1654A . . ...._... . . _._..... .---. . ..__.. . . .. . _ . ... . . .. _._.... . . .__.
L"JORKERS'CO�d.PENSATION DEClARA710N � ' "''.� '�� ' � 2
I hcreby afF�m ihat I have a certifita�e o(consent to self
... ._, . .__ . . . .. . . . . ... . .
insvie,o�ace�iilicatr.ofVlorkr.rs'�om���5o,�0���,�,o�«, APPLICATION FOR, BUILDING� PERMIT�
or a cr.riified copy ihereoF(Sec.3800,tab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �
PoI��yNfi . S_� 60-755(7ompaTipd�G Iy�l�mnity CO � '
a Ce.ti(ied copy is hcreby furnished. FOR APPLICANT TO FILL IN BU!IDING 2 1 �y(
ADDRESS I ��V
�� Certliie.d copy is filed with t e.county b Id' tsu��DinG
t n depnrtmenf. � A�DRESS 24418 St. Ives Ct. g.
Dote$ ' Applicant ' � UTY ' LP � LOULITY ' '
� C iIFIC TE OF EXEMPTION FROM W kKERS' ' � �� " - ' -- �--NO.OF 91DG5.� NEAREST �
..... .. . . .. ...,_
� COMPENSATION INSURANCE � SIZE OF LOT NOW ON tOi CRO55 ST.,
(ihis section need no�be completed if the permil is for onr. � -�� -� nS5E550F , � � � � �
.hundred dollars(3100)or less.j iRricr�� 42566� e�«K L T ' Z7 �;rP BOC�C PAGE PARCEL
t. usE ^� �.v+N
I certify tho�in Ihc performancc ot Ihc work for which this ��'�� ' ' p�Alt].e NO _ ��� � /����'�.� }
permit is issur.d,I sholl nol employ any person in any mcnner . qC:QE55 3187 A Airway Avenue � . . r�,�.� SVECIaL � �� � 1 �
so'as fo betome subjecl to Ihp Workcr5"Compensalion laws. CON'�ITIONS Q
, V
•--- . . .. arr . .Co a biesa ._ .-. _ ziP 92626 . _ . . . m
Do1e � 'Appli[onl A4CHITECT OR TEL. � I
' 'ZTICE TO APPLICANT: If, offer moking Ihis Cerlificv�e oi ENGi�EER �, � _ DiSiRICi G¢OUP NPE . F14E CkOCtSSED BY .
4nprion, you should hecome subjr.c� �o the Workers' - CO^�5 ZO!:E W
.,dmpensa+ion provisions of�he Lobor Cade,�you must(orlh• ACCREs3990 ?deStCYl••Pl ��170� N.B. 92660 l� �-3' � � �
wi�h comply wirh such provisions or this permil shall be" �� z
deemed re,voked. . . , TE�� S7aTi5TICAL CLASSiFKAiiOv APT. CONDp.
CONTRACfOR NO. c�..� .
IICENSED CONTRACTORS DECIA4ATION �� - � � ���. � � C1.n55�N0. ��/ �wEu.UN:75
I hereby afFirm that I am lice.nsed undr.r pro�isions oF Chopter 9 nDDeE55 k0. ,
(cammencing with Sr.ction 7000)of Division�ol the Dusiness ond . ....._ ... . ._ ���_ SEWER MAv
Professions Code,and my license is in(uil(orco and eifec�. �iTY ctASS B1 eK. � �eG. VALIDATION
� � 5 2 NO.OF NO.OF CNECK
license Number ��Z�1 Lic.Class S SiOR'ES FAI'.'.IL�ES 1 OIvE � �
�j � VALUATION . �� (7;y.�(�
COnlro[IO � � Da1r `� P DESCRIPTIOYOF WORX " '' """' ' " ' ' NEW s ZOZ JOO.00 � �
f
ACD � r.'• • • •2�
�I am ezem�l�nder Sec. � � � -" -�' ` .
ALTER ❑ n
8.8P.0 f Ihi rea�on � SFD - PLAN 4 REPAIR � s ' � � � �.�'G u 7�. .
� USE OF s
FXiSTihG CIDG. CEMOL ❑ . .. �.��!I n,�
Signa�ure � ArMKAni TE� FINAL �7 � �9.G 5��b
.Y�'R-8 L ER�ECLARATION eRiNi� �14h(f762-3�00 ..DATE ,5%Z�'S / -
�I hereby alfirm thal I om e pt Irom Ihe Coniroclor's License . . , , , •
law for ihc following reoson(Secticn 7031.5,Business and nDDRES !� W1 Ave. C.�1. 92fi2fi FINAL'� • �
'Pra(essions Code):'" ' " � '"� '" ' ' '� veESeht 8Y c�. � � � �
^7 �UIIDING '
\ I, as owner oF the properly, or my employer.s wiih AC�RE55 �� ��� �%�+��ii�
. � wc�es es!F.cir:c!^campensa:ion,will do the w�ork and ,
�� thc shutlure is nof intendcd or oifered for snie(Seclion ����T� �'- � ;'� •-0 •�• � 1
� 7044,Business and Prcfess�ons Code). � � MOViNG �- ��' - fEL� ' " ' � '
� I,as owner o!ihe property,am exclusively conhat�ing mvieaCiCR n0� , .•� � s S7 r 2.r O
with licenzed conr�aUors to'constivcr ihe P�ojr.cr(Seo- .. . . .. . . ... . ...._- . . . • . . .. . � y . .'.. - .
fion 7044,B�siness and Proiessions Code). /�DRE55 . � r;J���,-
� � CONSTRUCTION LENDING AGENCY SEI�HACK YARD HWY ��U��pRO�ICNEFR�,� WIDTH ' �
I hereby o1(irm that therr,is a consrruUion lending agency for f RONI , ' �'��5�a� �
Ihe performvnce o(ihe work for which Ihis permit�s issued� rL� -- � ���- - � ����� � � �� � -� • �� � —
(Sea 3097,Civ.C.). SiCe , '
. P.L. . .. . . � . ' .
Lr.nde�'s Nome �� , � � � . . .
���(yJ�/�� 7 LL� !� L�!:A Ref.M
... . . _ .. . ' P.C.FPP.E �+—�•/� PPrmil FP9 " � �
lender's/lddrr.ss y� f' � � �
I cerlify that I have r his applica�ion and srale Ihal the . p�4itiJ�' _../��✓I/ . lasuance Fee ��� � I�MA P/C* �� - - , , ' ,
abo e information i conect. gree fo tomply wilh all Co�nty Invesr�go+�on Fee p �f (� -� � .
o din, ces and S� ir wrre un,A fo building construUion, .. To�al Fee OSoG/O - LDUA Perm M � �
d he by othor e sem i�� tthis Cou ry�o emer , • ' , . � . • �
n Ih b ve-m �oned r r'for spectio purp cs. pf •
. .
. � i _ _ �tC�,�t'T�S' . ... _ _. _
SEE NFVFRSE FOR EXPLANATONY LANGUAGE , . .
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