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. ' �� � �
,. ... - �33 3.S� . _
' � . � SEE REVFRSE FOR EXVUNATORY LANGUAGE � �
� Signati of �rm���,n�em - � �oaro � . .. . .... .. . . ... . . . .... . .... .. ' : .. ..��
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