HomeMy WebLinkAbout1663A 1664A _ . . --- - . .._ .. .__..... ... ......_._ . __. _ _.. .. . ... ..._ .. . ..-- - - . . _ . _. ��
WORKERS'CO!AF'ENSATIDN DECLARATION '�' ' '�'` '' �'�' � � '
I hcreby affirm thnf I hove a cerlifitale o(mnsent to self
;�,���,o�oc��i�r�o��orwo�ke�:•Compensafion��=�.o�«, � � �-��--�APPLICATIDN��FOR BUILDING PERMIT �,
or a ceri�ried copy ihereor(sec:3800,tab.C.) �OUNTY OF LOS ANGELES BUILDING AND SAFETY
roi��yN��',�860-7556ompaF.rldu5 I�1lecdnitv Co. � � 1
�• Ce.t'rfied copy is hereby iur ished. ' FOR APPLICANT 70 FILL IN ADD7ES5 02 ��y J• �¢i • _
� Certiiied mpy is(iled with fh county iny pec- BURDiNG .
n �aoA rtmenl. �DORF55 Z4432 St. Ives Ct. ��•
Date� llppliCOM -- CITY ZIP lp('1�LITY
' C RTIFIC�TE OF EXEMPTION FROM R FR$'� "��' " � � � " " ���-" � � NO.OF OlDGS. � NEAREST
.. . ... .. . . _.. . . . . . _
� '� ' OM.PENSATION INSURANC � . Si2E CF lOi NOW ON lOi CROSS 5T.
(This sr.clion need not he complMed i(1ho pr.rmil is for one n55E5S0R _. � ""
__ . . . . .... .. . .. . ... . .
hvndred dollors(51�0)or�C55.) TRACT ���4256b BLOCK LQT N . 25 �aAP DOOK PAGE PARCEL
. own ��. . - . No. usE zone rM,Ao� I(-3�{
I terli(y Ihot in fhe prrlormonce of the work fer which Ihis . � — R�� �" I
permit is issved,I sholl nol employ any perso�in any monner . AOCVE55 3187 A Airw;� Avenue � ..... . - sPeani � a.
so os�o becomr subjeci to the Workers'Compensarion lows. a2`7z�O COhDITIONS ,v
_. . nTr . .Costa Dfesa z�P 92626 m
Datc Applicont pRCM1TECT OR TE�. _DIS1RiCT. GROUP TYfE. FIRE 'rROCE55F�BV � I
�ICE TO APPLICANT: li;afle.r moking�his Ceriiiimle o( ENG!nEFR s N — f0�� ZONE V
npiion, you should become sublett to'�he Wo.ke�i � ' /�
Lompensa�ion provisions of the ta6or Code,yoo must iorih- �coc[:39�0 `dc:;tCrl .PZ ii1�0� 1V.33. 92660 . lv ✓`"� �/ � � y
wilh comply wiih such provisions or this permi� SFIaII bP. ��� TEL. STATISTICALCLASSiFI�ATION � APT. COY�O.
deemed�evo�ed. • � � ' C04TRACTOR NO. /�� . ?
LICENSED CONTRACTORS DFClARA710N .- ' -�� � � � - liC:� ""•' � - Ctn55 NO.�_l�D'hTLL UNIT$ �
1 hr.reby nlGrm iho�I am Ilcensed under provisions of Chopler 9 ACDRESS NO. SEKiR l;Av
(commencin9 wieh Sec��on 70W)of Division J oF ihe Businnssand .__ , _._ ._. . . .__. �i�. '
Profess�ons Cafe,ond my Itcensr.is in full torce end rffect. CiTV C�n55 $1 BK �� � �' � ��YALIDATION
S � _2 NO.OF NO.OF CHECK ' '
License Number lic.Clas � 5 STORiES � iA�•.iliES 1 O"�`- � . ' � •� ,
■ � hFw.. • ..VAlUAT10N _ . . . .,
� " DESCRivTiO!�l OF V.'ORK ' - � �� 1]H,900.00 �
Conrracr r a/` • � Do�e 0 S r ��
i .... SFD — PLAN 2 ADD � . . .�1.6 6.3 i1 �..
�I om e.empl under Se.c. - " � � , .
lil7ER
— t �.• • . •C�
6.8P.0 for is reaiC , REPAIR��❑ � - �� ' � �
o�e�� E%S1�iNG BLDG. DE/fAl _ �.•:�7,8 6
Si nalure — ' APpuGaNf fEL. FINAI � • •(l��."'G'
� PR'NT� 714�:0.662-3700 '� �L �
OWNFR- UILDER DECIARATION . . _ . � DATE�-•S�Z{-�fi'7� � � -�—�
1 hereby affirm�hat I a eaemp�from the CoNractor i Limnse . ,. . ... • �A��—L�
low for�he follow�ng reoson(Section 7091.5,b�s�ness and ADoaE FINAI � -
PlofeSsions Code�: ' ' - "��� � N4E kN 0Y �L2.-i��
.—, cunoi�c
` I, os owner oi thc property, or my employees witb ADDR[55 . ..�� ',
/f wages as their snin mmpPnsn�ion,will do fhs w�rk cr.d � .;. � •.�.. � . ..
� the strvcture is not imended ar oilered for sale(Section lOfAIR� ��-' � -' �
7044,Business and Professio�s Code). "'' ��'� Y.AViXG � TFt.- � ' -��- � ' '� ` " e0� �'�4��' '
CONTRhC70R �O. �
� I,as awnrr o11he property,cm exdusively contracting , ..., a �. . ,. � • e . • r � .
wiih licensed coNrauors to conslrucl�he p�oject(Sr.n . . _ . ._ . . _. ... _ .. . _ . .. .... .. .. . . .._.-� :
fion 704a,B�siness nnd Proicssions Code). ADDRE55 � � r ,
� CONSTRUCTION IENDING�GENCY ' � � �� SEi BnCK vnRo NWY '�V�apHOP.iinEF�U'�� wiorti � - • � � ��a O G .
I hereby affirm Ihot�herc is a cons�ruction lending o�enCy�or �kUNi ' � . ' � ,'i',lA n�%`u
�Iha performonte of Ihe work for whith this permit is issued - �7.l � ---- � � � ' - � ���� " "' -�� ' " •'�' �
(Snc.3097,Civ.C.). SIDE � G�,�j?`�,(� �
.. . . . _.. r.t. . •�P . ._ ...'(o ` . . . .---... . . . .�
Lender's Nomn IDYA Re(.p � � .� �
. . . . .. . . P.C.Fee S Pnrmil Fcc ''� ' .
Lender's Address �` , ��
1 certify�hot I ha rr.od ihis oppli�oiion ond siate ihol the _.. ..p�{ 7�(/j�. is+m�ce Fer.-�� �-��.V�'- IDMA P/C M ��
above informa�i n is I a7ree lo comply with all Co�n1y �nvest��o��on Fne
ord�n ces an .ate la 'n 10 bvilding constrodion, . . . . .._. �- ToMI Fre� �/�� LD!dA Perm:M � �� - - - - �
hc by out oriz ep sema�n. of this County�o enier � �
u 1h a v lfone praprrry ior inspetli purp es. ' �� � �
,. ... - �33 3.S� . _
' � . � SEE REVFRSE FOR EXVUNAfORY LANGUAGE � �
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