HomeMy WebLinkAbout1669A 1670A .. ,- ._......-.. . .. . .... ...... ..._.... . _.. ._ . .._. . .
WORKERS'COMCENSATION DECIARATION ` '�'.: ' '.��' ~+ . •. ' ��
I he.reby aff�rm ihoi I hnve n certilicote of consenl lo self
insuie,orncr.n�fica�eoFVJorkers'Compensolion��,�.a�«. � �� ��� � APPLICATIQN FOR��:�BUILDIN�G�PERMIT� �� �,
or a cerriFicd copy ihr.'reoi(Sec.3800,lab.C.) � COUNTY OF LOS ANGELES BUILDING AND SAFETY � �
acyNaCC 860-7556ompabR(jUS Indennity Co -�
Certified copy is hereby lurnished: FOR APPLICANT TO FILL IN ADoeE55 .� ��' � �(n.Q.¢� �
� Gerlifir.d topy is Nlr,d wilh t touniy b��I ' in r. - BUitD!NG
u ndepprtmEnt. ADDRE55 24444 St. Ives Ct. cf�.
Dnte� Applicant CITY ZIP LOCALITY �
C TIFI TE OF EXEMPTIO FROM KERS' � - ` � -- �" "' " "" k0:C:BlDGS. - � niEnRESi _.__. ...._ _ .. . . . _ . _
COM{�ENSATION INSURANCE � � . Si1E OF I01 NOW OY lOT CROSS ST. ' �
(This sr.clion nr.ed nol be compleir.d if the permi�is for'onr. � � � - - ��� � - - � ASSESSOC,: . � � .
h�ndred dollars�5100)or Icss.) TaoCT !i2$66 C!OCK l 1 23 h'AP POOK PAGE PARCEL
��lif� Communities, Inc u5�zor,e r�?
I ceriily tha�fn�ho perlormance of ihe.work for which this Oti4h NO. _ n�� pp .�C� �}
i�
permit is issued,I zholl no�employ any person in ony manner . nnoRE55 3187 A Airwa �Avenue �-��- -�- ,Zor-�a CCN�ITIOVS O I
sQ as l0 6ecome suhjr.ct to thn.Workers'Compen'sotion laws. V
Da!e � A I�m��' • .. ;. . aTr .._. ..Me � ._ ..zir.. 2626---- �--� .. . . . . . . . .�
' TICE TO APPIICANT;If, afte.r mokin this Cerli(icote oi aRCHITECT OR Tf�• — DISIRICT GItOUP TYPE FIRE P40CESSED BV � I
9 FNG�NEFR f'
plion, you should becomr, s�bject�fo�the Workers' � � CO�vST� ZCNE V
�ompensa�ion provis�ons of!h�labcr Cod=,ycu musr lo�rh- nooRes�990 Sdesterl Pl ii 170� :V.B. 92660 I a. �3 �j,I 1. _ a
wiih comply wiih such provisions or�this permit shall be �� � rE�. �
deemed revoked. , � '... . STATISTICAI CIP.SSIFICATIOY r APT. COhDp. Z
. ..
CONTRACTOR NO.
LICENSED CONTR/1CTOR5 DECLARATION � �� - � - � ��� � ���. � MSS NO. D'hFLL UNITS � '
I hereby al(irm tha�I om licensed under provisions of Chop�er 9 A�DRF55 h0.
([ommenting wi'h Secrion 7000)cf D��is�on 3 of rhr,Bus�ness and .. _ . . . _.i��. s�vrtR M'°v � �
Professions Code,and my 17cense is in Iull force and effecl. Ciiv C�n55 B1 � �� �nK. p�. ��� ' ' ' VALIDATION
5 , 2 NO.CF NO.OF CkiECK
lirenseNumher �9�701 � �' Lic.Class � 5 Si02iE5 Q fAPAlLIES 1 � C!:E � �� b���•�
VALUATION
COnlraCt���. Dale� ^ CESCRIPf104 CF\L'p4K ' '' ' - ' �"� - . . .. .. 1-• • • �2 I .�
' � ADD � s
�1 am exempl under Sec. -. . .. . __.. .... ... .... ." __ _. . .._. _ ❑ , � o(:��.C:� .
SFD — PLAN 2 AITFR
B.BP.C.f r 1 's reaso . � S.. .. , � n o!;^!:�—
REPAIR. /.�...,;�
��p: USE OF
E%ISTiNG BIDG. C�l'.a ❑ Q��.11.r,"'�V .
� $ignolure _ APPLICANT 7E1. FINAL
R•6 �Df DECLARATION PR�!�i 714No.662-3700 � s �,�,
_ . DATE-- / v .. ..__... ...._'-....
I hr.reby affirm that I om empl irom ihe Co���ac�o�s t�cense.
� Lnw for ihr.following�e on(Settion 7031.5, Business and /+ooaF )/1 A' w� AVe. C.Pi. 92626 FINAL " ' '
Professions Code):- .. ._.... ... ....... - ruE r: BY ...- . . - � -
BURDING ,,Lb. ,�
; I,as owner of ehc property, o� my employees wiih ADCRESS . . _ ��;:�� =� u'i.~il�
� wages as ihe�r sole compe�soron,w�ll do rhe work ond ' � ' � �
ihe str�Uure is nol intended or ofFered for snln(Sec�ion �«AUTM ' •. e � � �� ,
7044,Business ond Professions Code). � "�"� � M.OVIhG �" ' - " " - TEL: � � � � � � ` -
� I,as owner of ihe propr.rty,am e�clusively tontracting COnIiRnCiOri h�� ' � ' � •'7 B.G.0 G..
..._ ...,. ...�
with licr.nsed conrraclors 10 constr�ct ihe project(Sr.c- �-�- �pDRF55 ,
t�on 7044,Dusiness and Professions Code). . � - ��-
.NEL'UI�lkU_ fOInL SEiBACK INiJ.•A xi ` ��`����=��'-'
� CONSTRUCTION IENDING AGENCY � � 5E1 BnCK YArtD tivvY pp07.I�NE NnDIH �
I herr.by afiirm tha�Ihere is a construciion lendin�ac�ency(or I�ipN� ' �' �n CI�—�G "
ihe perlormonce o(�he work for which this permi�ie issved � a l:�� � - �� - �- - � - � - •- �� �� �
(Sec.3097,Ci�.C.). s'°e �S7�� .. .. ... ..7/o.C1••`77- ' ' - . . . ,
. _ ... P.l. . _. . ... . . ,. .
Lend�r's Namc .
� LDhtA Ref.N �
lender's Address " " ' P.C.Fee 5 � Permli Fae��� '� '� �
. I ter�ify tha�I havo r ihis opplitation and stare tha��hc . /"��7�F....��� hnuo�ce fee-�- ��'v�� — LDMA P/C�. . . .
above inlormoiio correc� I ar,ree�o comply wiih all County In�e+i�goi�en Feo
ordi nce.s and !otc laws lotin to boilding cons�roction, Total Fcc-- ��a�--- LD!:A Pmm:�M �
d i reb ao! or' e �atrvr.;o(ihis C vnty lo r.nfer � � �� . � ��� ,.
on e bovc ., �one pro eny orinspeu n pu oses. �
. _...._. ... . .
- o�'d�-/�t�3�... . .... ._
� SEE REYERSE FOR EXPLANATORY LANCUAGE . . . � •
-' Siqnr.i i of pplimni or A9enf ' Doi . ... ._ .... ' .. . .. _... � � � ... m�
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