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HomeMy WebLinkAbout1667A 1668A (10) ._ .. . _. . . . . ... .. ..... . .. _.... ... . ...... _.... . 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 .. Siqnn�,e ol pplicant or A�em . . .poie . . ... .. .. . _ . . . . . ... . . . .. 7� � o 0 � T � C . � � � m ��o � G Q '? C� y o . o c+ v v �-N O C- 7 'O c� ; . O m � C1'O 7 G � � O �p 'C 0 U n f�'S� �' O � � �O � p n o �c o 3 � o� • � 3 � . " � ? z N. o? � � �' . Z� � �'% G �� y Q O� <� . � O • r j O Q G, O 7 '�O .7.y[p 'i O 0 y,e p n � O 7C � O 'i� ? 'O r -n C��' O ? � Q p ?' c i'� • ?; �O S 1 7 1 � . � .0 �0 f� � � � ` '� N ° ~ ` \• o � 9 "'\�^� °i � a�' � o. a '" y� � a p. Z �l c`r � , C�? ro � o Q � `� � � a � y . 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