HomeMy WebLinkAbout1649A 1650A (9) . . . ,. - --� —.---.... . . ... ... .... .._......_._..._.... ..._.. .. ---- ----- . .... .. .. _ . .. �.:
VlORKERS'COMPENSATIOY DECLARATION ; ..'- �. �" '. � . � � � ' � �
insu�ebora'ccrtifta'teoiVlorkers''Compensnlonslnsuran�" �� �-� � ���APPLICATION �FOR �BUILDING �PERMIT �� �
or a certifred ropy'rhereof(Sec.9800,�ab.C.) � CQUNTY OF LOS ANGELES BUILDING AND SAFETY - , �
vou�YN�C 860-7556ompoTijlaUS Inder�nitv Co.. . �p�
� Ce�i�fied ccpy�s he.reby(vrnished. FOR APPLICANT TO FILL IN ADDRF$$ � �02� �• ^P�� l�C..
� Certlfied topy is fiicd w' t �co ry �� e � � BV�ID�NG
r nde artmn.nl. ' ADCRE55 24424 St. Ives Ct. �,�j.
Dat n Applicant CITY LP LOCALITY '
C RTIFI TE OF ExEMPTION F OM RKE ' '' ' NO.OF BLOGS. - ��-�-- -� PI�AREST � -�- ���� '
� � OMPENSATION INSURANC ' SiZE OF LOT NOW ON LOT CRO55 ST. .
(Thfs sec�ion need noi be completed if the�r.rmit is(or onn � � -� � ASSESSOR. � , � '
hund�ed dollars(S�Oo)or less.) Tancr k2566 eiocK t T 26 /pqP 80CK PAGE P,aace�
. . . . . ... ., , _.. ... °� .. . . $E,Zp,.,Nk IMP
'� Ol'Jk � N• �E/T NO. ����� �
I certi(y Ihat in iha performance ol fhr work for which�his — �� � �} �
pe.rmil is issvcd,I sholl not employ any pe.rsan in any manner . �C�QESS-31 H� A A�YWII}� AVCllUC /�� 5�'FCIAI - � � �-� �� �� 0. �
so as l0 6etomr.subjecf to Ihe\Yarkcrs'Campensatio�Lows. �� ��� � � a-OC�C�C� CONJITIONS 0
. , � v
Dale Applimnt � .. . . CITV . COSC1 P�CSH .. ZIP 92626 . . ' . . . _ . . p�
"1TICE TO APMICANT: If, af�er making this Ccrtificote of ARCHITCCTOR TEt. _ � I
DISiRICT CROUP TYPE fIRE PkOCESStD dY .
{nplion, you shauld become su6jecf la the Workers' FNGIhIfR N CONS 20NE V
� �ompr.nsntion pravisions of�hr.Labor Code,yo��must fnnh- nD'u�E5�9�O IdCsteLl} �1 "170 N.I3. 92660 �J �-3 �j. Z - W
wiih camply wi�h such prorisions or this permil shall 6n � N
deemrd revoked. �� � • � T«• SfAT15TICAL C1A55:FICATION . APT. CO�DO, �
CONTRhCTCR S�me i1S �0.'i1CT' NO. a—.�
LICENSCD CONTRACTORS DECLARATION � � �-- �� � �i�. � � �� - QASS NO. °v DwELL UN�TS�
I hereby o(flrm Ihot I am licensed under provisions of Chaptrr 9 ADCRESS NO. ��R rf�P
(commencing i�h SeUion 7000)of D�vision 3 of tha Business and , , .. . .. .. . . �i�.. . . �
Profesvons Code,and my I�cense is in fuli(orce and effact. CrtY C�n55 B 1 eK. PG. ' VAIIDATION �
� S 27 5 NO.OF _ NO.O�. CHECK � ' . .
ucense Num6e: 393701 �;c.ei�, � s�� 6 9 STOR'ES Z-- FA!AltlfS 1 �- ONE �1 6�,�i l�
� / /� p '�{n CESCRIPTICN CF l5'OFK � - " " - "
/ / VAIUATION
Conlractdr�^ll=��.4 ' Date o w pp ..O f . . . .. . =� • • •?�
. 2�2 �0�:��
I am eKn.m t under Sec. ��� - - `��� �— -
� SFll - PLAN 4 A�TER � r •:,�o a 7 0 �
B.BP.C.� r 1 'S re son . RFPAIR � .s ._. . __ . . s e�j�G. !Q u
� ��D r.: USE OF •
EXISTING BIDG. CFMOL ❑ �
. .. . _
Signatu�c APF`LICANT TEL FINAL . � C`^i, J��6 •
(PRINTI 714„�62-3700 _ �7 .
WNER-0 �DER ECLl�RATION __ . � �DATE��-� �—Z —� " '"'" '""" '�� "' �- ''
I hr.rr.by affirm that I am e mp�Irom�he ConiroUor i licr.nse 92626 �� •�-�� • � � � ��
lew for�he iollowinA reason(Sec�ion 7031.5,Business ond nDDRE5�1B� A AlTW3 l�Ve.� C..Tt.� FINAL � "' ' •
'PrOTCSsions Code): ' ' -" ""'" ' ' PRES[N BY /��`...i-.r � � � ��� � � ,
� BUIl01hG .. .- ..... .. . , . .
I, as owncr of thc propr.riy, or my rtmployecs wiiti neCriE55 %� � �:�li
w�ages as Iheir sole compenso�ion,w�ll dv�he worR and
� thn snvcture is no�iniended or aflered(o�sa�e(Section �a���TY , � � �:•. • • e t
' 704a,6usiness and Professions Code): � MOViNG �- ' � TFt.' � �-� � � �- . �� �
� I,as owner of thn properly,am exclusively cantracling C0ITRAC70R . . .. .. NO... _. _-. . . . .' " . � •r J 2.U�
wi�h licensed contrac�ors fo construc��he project(Sec-' � � � � �
tion 7044,9usiness ond Professions Code). ADCRESS , , . _ • •{�`f.C r J
. . . NFUUIRFD. iUiAL5E1BACKfNu.'A Ri T.
CONSTRUCTION LENDING AGENCY 5E�BnCK Y�+RD HWY pROP.LINE WiDTH
I hr.re6y afffrm ihot ihero�s o tons�ruUion Iending agency for ruo�r �� � . � G 9.G J—U O
ihe performonce of the work for which�his pe.rmit is issued � � � vl. � �- � -� ���
(Sec.3097,Civ.C.). - SicE ' �
. . .. . P.l. . . . , . .
le.nde:s Nome
I` /,� l•� . LD.+AA Rel.p . ' � �
lrndc�s Address " P.C.Fee 3 �Q•7✓ PPrm�t Fee d � �
.1 terfify thol 1 hove read�his applicalion and sfa�e Iha��he . i�i!'wfr} �'� Issunnce Fee �J-'S� �DMA P/C M , � - .
ob ve in(ormali ' recl,I ogree to comply wilh all Couny in�es��gai�on tee
o�d� onces a Slato Iaiing ro building conslruuion, ,.. . . ._ . .... .. . To�al Fer.��� G � '
a d .reby o Iho' rr,pr se i !'ves of fhis Cauny to r.nter J��� �CMA Pcrm:N� � � � . � �
e bo en�ione p ty for inspecli n purp es. y /. . .
. - . ... ..__.. �X�{4,y�-7�C . ' _ . . . . . . . .
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