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HomeMy WebLinkAbout1669A 1670A (10) .. ,- ._......-.. . .. . .... ...... ..._.... . _.. ._ . .._. . . 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� . � x o� � � ,o / .`. . 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