HomeMy WebLinkAbout1667A 1668A ._ .. . _. . . . . ... .. .....
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WORKERS'COh5REN5ATI0N DECLARATION �. '• �• .'�"-� � � _ ' • '
I hereby a11�rm tha�1 havc o ce��ificate oi tonsenl io self
. .. ....._ . . . _ . . . .
insurc,oracertif�cnicoFWorkeri Compensa��o���,��e�«, APPLICATION���FOR.��BUILDING PERMIT�
or a cr,�uF�r.d copy�hernof(Sec.3800,lali.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY •
Pol�cyN�'(: R60-755(b,.�padatd�G n 1 mn y
� Cer��tied copy�s hereby(�rnished. FOR APPLICANT TO FILL IN su'IDiNG z J �[ /}�
ADDRCSS / J • +'��4/ �iti •
� Cr.rtificd copy is filed wii i e ounfy i i in e AUiLDiNG ,
r� ndeppnmenl: ADDRESS 24447 St. Ives Ct. ,�.f3•
DatB� J Appli[Onl CIiY • ZIP IOGALITY
ERTIFI ATE OF EXEMPilO FROM RK RS' "�""
' NO.OF BLDGS. ' ' NFARCSi ... . . . . ._ . ,. . . ... . .._.. ,... ,.. .
COMPENSATION INSURAN � SIZE OF LOT NOw ON lOT CRO55 ST. �
(This sr.ction need not be comple�ed i(the permir is(or'onr. - -- 4LS66 � 1H n55E550R . , '
h�nd�ed dollars(SI00)or less.� . irtncr � niocK � �Oi7�b4 MAP BOOK OAGE PARCEL
o,,,M�alif Cor�munities, Inc ti�i62-3700 us��NE �P �I_��
1 reHify ihat in ihe perlormoncc of�hc work for which this S � .}
pv,rmil is issued,I shall not employ any prrson in ony manner ,.._. ADDRESS 318� A �1YW1 � - � S�'ECIAL � d �
so as lo be.came subjr.cl to 1he Workers Compensation Lows. COhDIT10N5 �
V
Dafe Applicanl . CITY. . CC7R a :fe�a ._. z�P 92626 - - .. . .. . ... - . .m
'�TICE TO AP%.ICANT:�If, offer ma4ing thi5 Certificate of ARCHITECT O4 . TE�. ,.DISiRICT. GROUP IYpE fIRE PkOCt55ED 9Y . ,� I
� ENG'NFER — Cp,yST ZONE V
,�ption, yo� should 6ecome s�bjr.N to the Workers' ' � �� •
�ompensation pro��s�ons o(rhe lobor Codr.,you m�sr fonh- F�p;[u 3990 F?e,teTl' Pl ;:�1]0 N.B. 92660. IO �� � . � a
wi�h comply w�th such provlsions or �his permii shall be �
TEL. STIITISTICAL QASSIFICATION APT. �ONDO. '�
deemed revoked.� � � � •,� CONTRACTOR NO. ' ,y�
IICENSED CONTRACTORS DECIARATION � • � �� � � � �� � �i�. Q�SS NO. �7 DRtIL.UNITS_L_
1 hereby offirm�hot I om licensed under provisions of Cheptcr 9 AD�RC55 h�.393701
([ommencing with Section 7000)of Division 3 of�he Business and . _ . ._ _.. . . , . ��� SEWFR MAP �
Professions Codn,and my license is in full lorcr.ond e(fett. CI C1A55 B 1 �BK:- ���: � ' " VALIDATION
� . 5 . ` NO.OF NO.OF, CHECK . •
L�cense Number "1997f11 � Lic.Closs � si sTo2ies � Farn�ues 1 ONE •
VALUATION.
eo�r.a���.���.� . Daie� OESCR�DTION OF Yro�K-- �� � :;1 G�.7 A -.
SPD — Plan 2 ADD � s
❑I am e*emp�under Sec. � � ,, ,. • • •2�
�LTCR
B.BP.C. or�hi reason ....s ... . . . . � c L
� � REPAIR � I ^�l v 7,��l:
pa� : USEOF CF:'OL � �
' EXISTING PIDG. ❑ ' �
� Signatore� . nvPUCANT fEt FINAL ' -° e:i�C!,�''�;�:
OWNER-B �ER DECLARATION IFRINT� �l�f Nc662-3700 DATE- `` ... .. . . ,= r
-I hereby aifirm that I am empl from ihe Conrroctor's license S�"!I`u7 1 _ . �'J—^� � .
Law for the following reoson�SeUion 7031.5,Business and ADoaE55 A A' A C.�`i. ?�Zfi FINAL ' �
- ProfesS�onsCodr.):.. .. . _ ' .... .. � FkE�n� BY � � �ti�, �
^-� BUILDING ,
\ I, as owner of�he properly, or my rmployecs wilh aDDQESS
1 wages as�hcir sol^campr.nsnlion,will do the work and . .., G���
ihe shucfure is not iniended or offered for sale(Seciion IOCnLitt ' �� � ,
- � 704a,Busin�ss ond Profeuions Code). �� � � hlOV!NG - - � ' TEt. � �� � �
� I,OS oWnef O�IhC properly,am eaclusively contracling CONTRACTCQ NO. "' ',-� ' .��,_ � �:�• • • • e � . '
wi�h licensed con�rac�ors to construcr the projecr�Sec• � �� qooaE55 � '
�ion 70Ad,Business and Pro(essions Code). , , . ,� • ��-t`1 d�
� � CONSiRUCiIONIENDINGAGENCY' �� ' ` WE�gq�K YARD HWY �V�AFROP IINEfkUM �� '�yIDTH ��
�-� • ° /j.;C��QC
I herrby n(lirm tho��here is a tonstruclion Ir,nding ogency for f NUNI ;'t�\,'���; ;4.•`.�-� �
fhc periormancc of Iha work far which Ihis permit is issued G L - �� � � � � - � ' . � ����U J_S V :�
(Sr.c.3Q97.Civ.C.). SioE . . '
. .. . . . . . P.L. .. _ . . . -. .. .
Lr.nder i Name .
� l0:'A Ref.M '
� � � � P.C.fee S . Perrii�Fee �
Lender i Address d,� q , � �
. I cerlify Ihat I ho .ad this appliwtion and stofe thal Ihr. O�s��-��}- /S�Cl� � Issunn<e Fee ���'� IDMA P/C M ' � -
above informati n is ro t.I aqrer.lo comply with oll Co�nty Invnsn�o��on Fcr. , �
ordi nces an �cq ro building constroc�ion, .._ � - Toiol rce '�� � iD:!n Perm.N
nd h rcby ai orizc repr sen iive�of ihis County lo enfer ,
p n I e bov -menlionc p�oA «Y ���spPctlo puip es. . . � '
� - '�1f 3-.� ;. . .. . .
, � � SEE REVERSE FOR EXPLANATORY LANGUAGE
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