HomeMy WebLinkAbout1675A 1676A (10) ._.. -- �- . .. .__....._.._.._ . _ ... .......... . .------- -_._ . 1�1 WORKERS'COMFENSATION DFCLARATION '�' • '�'�'�� � • �� ��� I hereby o11��m ihnr I hnvr. a cerlllim�e of mnsenr io self _ .. . .. ' '. ' .... insurr.,orncerli(im�eolWorkers'�om�P�,o„o�,�5��o��e. ��� APPLICATI4.N FOR .BUILDING PERMIT �- . or a cr.rtlffed mpy iherea (Sec.3800,Lab.C.) �OUNTY OF LOS ANGELES BUILDING AND SAFETY � . aoucyNo.i'G Ab0755CtomPa��n1�s Indemni.tv Co � � � Certified c�py is hc�c6y fomished. � FOR APPLICANT TO FILL IN BUILDING a� �I � • . ADD4E55 � Cr.rtified copy is fi�ed ith� coumy uild' mspe- BU401NG • r n depar menl. ADDRC55 24441 St. Ives Ct. ,!S•� . - Dotc Applican ITY • ZiP IOCAI�TY � C RTIFIC TE OF EXEMPTIO FROM W �tKER$' �' ' ' NO.Of y(pCS. - ��� �� . NEARESi ... ' � � � COMPENSATION INSURANCE S�ZE OF lOT NOV!ON l0T CRO55 ST. � (This secfion need not be completed if the p.rmit is for onr. � � - � - a55E550R � hUnf�/ed dpllOrS($100)Of less.) , TfiA[f 42566 � e�ocK � ior No. 17 N,AP 600K � PAGE PARQI 1EL. U ZONE h`a' . . )�!_ OVvMER I I certify Ihat in Iti!!p�rlormonce ei the work for which this � — ��,1� �� � f T permit is issucd,I shall not r.mploy any person in any manner ADDRfS$'31 H7 A Airw� . . sF�ci°'i..� � � a so as to becamr.suhject to ihe Workers'Compensotion laws. y COtiDITIONS '0 . , u oare aP�i�c��r ciTY a Mesa. z�P 92626 _ . . Qa ARCHITECT O I • .�' TICE TO APPLICANT: If, oiter moking thiz Certilicale of FNGINFFR Arari Bassenian ��W�SZ—iH6�i � DISIR!CT.. G�70UP TYPE � . FIXE IM:OCESSE06Y .;F -nption, you should become subjecl lo Ihe Workers' J� CCn�.�S,�_, ZOtiE . V � P Y ACCRE55 3990 Sdesterl� Pl. i�l�� W a,�m ensoiion rovisions of the labor Code, ou m�st forth- � ,I.B.9266 f(� 9t-3 O. wilh tomply wilh such prOvitions or Ihis permil shall bt± T[l. STATISiIUt QASS'FICAiION �DT. CONDO. z deemed revoked.� � Co4TRACT04 NO. �..,! . ... . � LICENSFD CONTRACTORS DECLA4ATION � � � � � � - � - �i�. � QA55 NO. �� D'.vELL.uNiTS I here6y a(firm iha�I am licensed under provisions of Chap�rr 9 nDDZE55 No.393701 (tommr,ncing with Section 7000)of Division 3 of ihe B�siness and ... ��� SEYlER�IJ�P � Pro(essions Codr.,nnd my license is in fuil force and efiect. [ Ctn55 B 1 � Rr. ���, � � VALIDATION � " ` NO.O', NO.OF CHECK ' License Number llc.Class� 5 , STOR!ES 2 FAMIIIE$ 1 ONE � VAWATION„ . � J' L'ESCRIFf10N OF Wp^.0 ' NEW Contratl � ' �� Da+e . .. . ._ . . nDD � s "' � (:j'��' ' �I am eaempl onder Sec. ��� �-� ' - - , �.� � . SFD — Plan 1 A�TER � •F_� 8.8P.C.for thi ICOSOn . REPAIR.� � _ � �� � , � ��� � � �� USE OF ❑ I�'t IL�,(�� e: D'��.IX E%ISTING OIDG. � � � � � - Si9nafure � APPLiCANf . T[l. FINAL � a a({(l� %{)�; raiNi� 714vo.662-3700 � WNER-B 6DER ECLARATION . � DATE�--y-.-L ��' � -� �- �� � -.r- •• -� � I hnreby aflirm iho�I am e�mpt from�ha Conhaclor's License 1$] f� Airway, C..PS.� 92626 � , , . �V�,�1�`�� Law for the fotlowin�rca on(Section 7031.5, 6usiness and ADDRES� FlNAL���� � . � Pro/essions Code): "- � "'� " ""'� " kE[n BY " ' . r� CUILD:NG , � ; . . � � I, as owner of the propr.rty, ar my employnes wiih AnDVF55 � wag�s as the�r sole cempensa!ion,will do the wcrk and � � � �he siructure is not inlendr.d or olfcred for sale(Seclion �aA��TY , . � O 7•J� 7044,Buslness and Professions Cade). "' � M�OViNG � TFt. - � � � ��- . , � � I,os owner of the piopr.rly,am evclusively conkocling CONTRACTO4 NO. � � _ • • • • s � . with licensed controctors�o cansirucl Ihr,projecl(Src- �DD4E55 I • !:,'�Q Q lion 7044,Businrss and Pro(essions Codr.). • . REOUI2ED IOTnlSiiaACK:R . XI I. . . .. . .. � CONSTRUCTION LENDING AGENCY � � ��� Ser anCK YnaD rnw vuor.une w!afr� , �''"� - I hereby a(firm thaf there is o tons�ruction lending agency for fRUNt ��!���7(�y ihe performance oi ihe wark ior which this pe�mit is issued �P t. - - - �� � (I G,(}J"t�G (Sec.3097,Civ.C.�. SioE • � ' . .. . P.l. _. . .._ . . ' . lender's Name . � � � . 7�a�� lDhSA ReF.N Lender's Address � � " P.C.Fec 5��-- � � Porm��Fee � � � � � �� I cnrify iha�1 havc read ihis applico�ion ond s�a�c that the . 75�� hs�a�ce F�� � /�'�- LDMA P/C M- ,� � � � - - � obovo'niormotion'� agrcc 10 comply wilh all Counly Imesn9o��on Fee �J�t-7 , . �d�no�es a d 5 io building consnuci�on. .. . ._. .. To�ol F�� ��-/"`�'U� io�nn a��m.x . .. . n hcr by �h o rr,presen o've (this County�a en�r.r _ . � � n th abc e- � ti . e, for �spection npose ..._.. . ... � SEE REVERSE FOR E%PLANATORY IAHGUl1���� , � . ,gnolur Inf App rant nr Agen1 le' ' - "' . . . . . .. . '. . .. .. . . .. 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