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HomeMy WebLinkAbout1663A 1664A (9) _ . . --- ._ . __ .. . ... ... ......-.__ __. _ _.. .. . ... ..._ .. . ..__ _ . . . _ _ _. �� W02KER5'CO!AF'ENSATIDN DECLARATION '�' ' '�'` '' �'�' � � ' I hereby affirm thn�I hove a ce�Aificole o(mnsent to self ;�,���,o�oc��i�r�o��orwo�ke�:•Compensafion��=�.o�«, � � �-��--�APPLICATIQN��FOR BUILDING PERMIT �, or a cer��Red copy�hercor(sec:3800,tab.C.) �OUNTY OF LOS ANGELES BUILDING AND SAFETY Policy�7��',�860-7556ompaF.rtd�s In 1 ni v Co. � � 1 �• Ce�iii�ed copy is hereby fur ished. ' FOR APPLICANT TO FIIL IN ADD7ES5 02 ��y J• �¢i • _ � Certiiied tOpy is(�Ied with th county iny pec- BWIDiNG . n �d�A rtmenl. �DORF55 Z4432 St. Ives Ct. •�• Dole� l�ppliConl -- GTY ZIP lpCAtITY ' C RTIFIC�TE OF EXEMPTION FROM R FR$'� "��' " � � � " " ���-" � � NO.OF OlDGS. � NEAREST .. . ... .. . . _.. . . . . . _ � '� ' O.MPENSATION INSURANC � . Si2E CF lOi NOW ON tOT CRO55 ST. (This sr.clion need not be complMed i(1ho pr.rmil is for one n55E5SOe _. � "" __ . . . . .... .. . .. . ... . . h�ndred dollors(5100�or IC55.) TRACT ���4256b BLOCK LQT N . 25 �rAP OOOK PAGE PARCEL . . . O1VN "• . . . ' • .. NO. � USE ZO�E �W ��_3 Y I cerli(y Ihat in fhe prrlormonce of the work fer which Ihis . � ' R��j �" I permit is issved,I sholl nol employ any perso�in any monner . pOCVE55 3187 A Airw;� Avenue � ..... . . sPeani � a. so os�o becomr subjeci to the Workers'Compensarion lows. a4`7��0 COhDITIONS ,v aTr . .Costa Dfesa z�P 92626 m Datc Applicont ARCMITECT OR TE�. _ DIS1HiCT. GROUP TYPE. FIRE `rROCE55FD BV � I �ICE TO APPtlCANT: li;afle.r moking ihis Ceriiiimle o( ENG!nEFR s N - f0��' ZONE V npiion, you should become sublett to'�he Wo�ke�i � ' �ompnnsmton provisions of the ta6or Code,yo�must ior�h- �coce:39�O jdc:;texl .Pl ii170� N.33. 92660 tv �'� �/ � � a wilh [Omply wilh such provisions or this permil SFIaII bP. ��� TEL. $TATISTICALCLASSiFICNTION APT. COY�O. � Z deemed�ev0�ed. � � � ' �pyTRACTOR NO. /�� . J LICENSED CONTRACTORS DFCIARAlION .- ' -�� � � � - liC:� ""•' � - Ctn55 NO.�_l�D'hTLL UNITS � 1 hr.reby nfffrm tho�I am I�censed under provisions of Chop�cr 9 ACDRESS NO. SE15iR Mp� (commencing wieh Sec��on 70W)of Division J oF ihe Businnssand .__ . _._ ._. . . .__. �i�. ' Prafess�ons Cafe,ond my Itcensr.is in full torce end rffect. CRV fin55 B1 BK �� � "' � ��YAUDATION S , _2 NO.OF NO.OF CHECK ' ' License Number lic.Clas � 5 STORiES � iA�•.iliES 1 O"�`- � . • � •� , . ..VAlUAT10N _ , . . .. ■ � � " DESCRi�'TION OF V.'ORK ' � �� hFw� 1]H��OO.OO Conrracr r �/` • � Do�e 0 S r �� i SFD — PLAN 2 . "o� � . . .�1.6 6.3 i1 �I om e.empl under Se.c. - " � � , , . . . .... .. . .. . ld7ER j.• • • •C1 6.8P.0 (or is reaiC . REPAIR..❑ -- t � ' �� - - ' ' � oo�e�� E%S1�iNG 6LDG. DE/JAl �.•:�7,8 6 Si nalure — � APPLIG4Nf fEL. FINAL � • •(l i��."G' � PP'NT) 714�:0.662-3700 '� �i � OVINFR- UILDER DECLARATION . . _ . � DATE�-•S�Z{-�fi'7� � � -�-� 1 hereby affirm�ha�I a eaemp�fram the Conrractor i License . ,. . ... • �A��-G� low for�he follow�ng reoson(Section 7091.5,4os�ness and ADoaE fINAI � � n • • PlofeSsions COde�: ' � - "��� � F4E kN eY ��L2.-i�� .—, cunoir:c , I, os owner oi the property, or my e.mpioyees with ADDR[55 . ..�� ', /f wages as their sniw mmpPnsa�ion,will do fh^w�rk cr.d � .:. � •.�.. � . .. � the strvcture is no1 inlended ar otlered for sale(Section lOfAIRV ��-' � -' � 7044,Business and Professio�s Code). "' ��'� Y.AViXG � TEt.- � ' -��- � ' '� ` " eP� �'����' ' coNTanctev �o. � I,as awner a11he property.cm exdusively coNracting , .... •i �. . ,. � • e . • r � . wiih licensed coNrauors to mnslrucl�he p�oject(Sr.n . . _ . ._ . . _. ... _ .. . _ . .. .... .. .. . . .._.-� �: fion 704a,B�siness nnd Proicssions Code). ADDRE55 � � r , � CONSTRUCTION IENDING AGENCY � � � �� SEi BnCK vnRo NWY '�V�apHOP.iinEF�U'�� wiorti � ' • /V a�� � I hereby affirm Ihol�herc is a cons�ruction lending o�enCy for feUr+i ' � . ` � ,'i',lA n�%`u �Iha performonte of Ihe work for whitb this permit is issued - �P.l � ---- � � � ' ' � ���� " "' -�� ' " •'�' ' (Snc.3097,Civ.C.). SIDE � C�,�j?`�(� � .. r.t. . •�P . ._ ...7(0 ` . . . .---... . . . .� Lender's Nomn . . . _.. IDYA Re(.p . � . . . . . . .. . . P.C.Fee S Pnrmil Fcc ''� ' . Lender's Address �{ , �� 1 cerfiiy�ho�I ha rr.ad ihVs opplim�ion ond s�ate�hol the _.. _.p� 7�(Jj�. is�m�ce Fer.-�� �-��.V�'- IDMA P/C M �� abOve informali 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 Fee� �/�� LD!dA Perm:M � �� - - - - � hc by out oriz ep sema�iv. of this Counry�o enier � � u 1h a v lfone praprrry ior inspetli purp es. 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