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HomeMy WebLinkAbout1677A 1678A (10) , , . , _ .. .. . ---�-_ _____.. __.. . .... . _ ..... ---.. _. ..._. 1S .. _.....-- -.. .... ........ . _._ ._. ' WORKERS'CO'APENSATIONDECLARATION ������ '�" � � ' �' ' .. .. ......._.._ �. . . 1 hr.reby a{�;�m ihol I hove a certificaie of consen�fo s��F —-��1PPLICATION �F�OR �BUILDING PERMIT-- �� ��� insure,or o certifico�e of Wo�kr.rs'Compensation Insurnnce, o�o certifirtd copy�he.reof(Sec.3800,lob.C.) ' ' � � ' � � -�� - Poltc NoEC 860755FiCom COUNTY OF LOS ANGELES BUILDING AND SAFETY . y PEqdus.. Indmni.ty Co. � Cenifie.d copy is hcreby(urnished. OR APPLICANi TO FILL IN BVIIDING �� �/- N �p�. ADOGCSS `W�l.'Q/ � Crriified copy is filed with t co��t hui � .. ec- A�IIDING ito depa tmr.nt. ADDRE55 SC. Ives CT. � /,3 oa�e'� n�,�i�c�oi \ � arr Q ziv iaca.uTr � C RTIFIC TE OF EXEMPTIO FROM 4KERS' "' "-"'" ' • ' '" ' " NO.CF 9LDGS. ' � �" NEAREST... � �COMPENSATIDN INSURANC SIZE Of LOT NOW ON lpi CRO55 ST. (This section�need no1 be mmpleted ii Ihe permit is for one �� ���- �- �-�-� - a55650R , � • � � . � hundred dollors(SI00)or less.) TRACT 42566 � e�«K LOT k0. 15 I�Mp t30CK 7AGE PARCEL o�vriraCalif. Comnunities IneNF< < use one mnr ���,� I cer�ify ihct in�he performante of ihe work for wh�ch�h�s — ��/� NO. � � y pr.rmit is issurd,I shail no�employ ony p�rson in ony mo��er AD'�RE55 31 HJ A A�YWiI ��VCRUC ���A�� n' � so as ro 6ecome subject to the VJorkeri Compensation laws. � y �� ���� CONDITIONS Q Do�e � Applicont • Ciiv Costn 4fesa ziP 92626 �� ' . " ��- ,- � "'iTICE TO APPLICANT: IF, of�r.r moking th�s Cr.rtificole of ARCHiTFCT04 T��. _ D!SfRICT GROUP 1YPE . . FIRE PNOCESSfDBY � I 4n �ian, FNf,INFFR N� CONST ZOY ~ � p you should become sublect io the Workeri - ' i ` p . �U tampensalion prowisions o(Ihe Labo�Code,you mus�forih- ;,DDRE5539�0 ���CSCCTl� Pl. :r 17D� N.T3 92660 (v. !C� � � P`Y y wifh camply wilh such provisions or ihis permit shall be' 1E1. STATISTICAL C1A55'FICATION APT. CONDO.� y deemrd revoked. . 2 CONTRACTOR NO. IICENSEDCONTRACTORSDECIARATION � �� � � � �� � ii�, anSSNO.�DvvELL.UNiTS I hereby aFfirm Ihal l am licensed undr.r provisions of Chopfer 9 AD�RE55 No. 393701 � (camme.ncing wi�h Sr.c�Ion 7000)of Division 7 oi ihe Bus�ness and __ ._ _��� SEWCR NAa Professions Code,ond my license is in full(orce and efiect. CiTY C�n55 B 1 �6K - � � - . "VALIDATION � �] 19��_ 1�'O.OF NO.OF C�IECK , . lkenicNumbr,r �q�7n1 Lic.Closs ` IZ 6 STOR!ES���� Z� FAMILIES 1 or.�e • � , • VAIUATION. : � ��,7 Fi CFSCRIPTIOYOFYJORK ' � NF1J...� 169�9��.�� Con�ractar • Dolc � AOD � s �� T �IameKr.mptunderSn.c. .S.F.D. —.Plan 1 .. . , � � � �� ALTER � � e(.�1�,�I� . B.SP.C. r his cason REPaIR.Q s ' "'"' � ' " ' � USE CF O ' • ���.7�^T: F%IS7ING AIDG. DE.S'.OL _. .°�� . . -. Si�nafure APPIIUNi �F�� FINAL U�.G�--E 6 . JNE -8UI DER ECIARATION IPRINT� N� � DATE� �Z �C ... .. .. _. .. . I hereby af(irm iha�1 om ez p�from the Contractor's license 92626 � � • � • •• � � Law for ihe foilowing reas (Sectian 7031.5,Business and Aooaes�187A Airwav [�V2. C.Tt.• FINAI P.ofessions Code): -� � " " Nkt n� BY `, �� � � � ^ BURDING . l �.. -. .. 1 I, ns owner oF the proprtrty, o�my employees wi�h noCaE55 '�� %�� (;�,-��1 �:•eges es fhcir so!c camper.sa:ion,will do the work and Ihe struclure iz nol intendrd or of(ered for sale(Section ��`��TY , � • e . • � ' � 70E4,Business ond Pro(essions Code�. �- ' h�Ov:rlG - � � � �TEL. ' ' . � � - � � : . - :�... . . . '�. � I,as owner of Ihe property,om eKclusively cantracting CC4TRACTCR NO. , . � � ;� � . . � ��.QC with licr.nsed tontrocto�s 10 constr�cl Ihe projr.ct(Sec- nDDRf55 lion 704E,8usiness and Professions Code). � ,�y a�i�� CONSTRUCTION LENDING AGENCY — .REOwaED fOIAI SkIBAIY.hNUM �xi .. . .. . .... . . YARD HWY SEI BACK FNO°.IINE WiDfH I hr.reby affiim ihat there is a constr�cfion lendinp o9ency for kRUNI � ' . G�'.n��n� the performonte of thr,work for whith lhis pe�mil is issued �� v.L - �• � - (Sec.3097,Civ.C.J. SiDE - � P.l. Lendr.r's Nome FJ " -7 / Z•S 7� lD!M ReF.M � ' ' .. . . . . .. P.C.fPP S ' �I•/ Pcrmii Fcrt�� � lender's llddrr.ss � I certify�ho�I hove rend 1hi5 opplitalion ond slata Ihat the . � _ �S�� Issua�c.Fen .����D IDMA P/CM � � . _ .. ..... . . .._.. . . . obove informotio �s corre . agreo lo[omply wiih all Counry in.esugo��nn Fec � o�din�nces o�d tale �o building constr�clion, . _ . .. � To�ol Fee� ����"��O LDM,A Perm:N - 1� � -� � he�eby auth ' reseni tiv o i Co�nty to en�er . � u ff 6 vc- tionr.d pro .rty or in ctlio p�rpos 5. (��1 . ___.. ... . ... ^ _ .;... .. _.. . ' -.. . . � - . � ... . . _ . .. . . �C"r7� �� • `. ��.�� ��� SEE REVERSE FOR E%PLANATORY L1INGUAGE S�Nr o1 p I�con�or gen +e '.._ .. . . . .' 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