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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