HomeMy WebLinkAbout1647A 1648A . ...._..._. .... ...... ..._ . ..
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WORKERS'CO•41FENSATION DECLARA710N %�� `�. ';` � . �� � " �� � ' Z
Iherebyo«,�mihnt� �a��ocerli(icpleo��o�se�,��o,e�{ - � � ��� �-�APPLICATION FOR�.BUILDING �PERIIAIT�- ��� �
insure,or a ccr�ificaie of Workers'Compensation Insurance,
o�a cmrhed copy ihereof(Sec.3800,lob.C.) � COUNTY OF LOS ANGELES BUILDING AND$AFETY
Po1�cyN�FC R60-7556omFaaa['ILR IIIdE+mlt1,�,V (�O.- gURDING ��e
� Cenified copy is hereby furn�shad. FOR APPLICANT TO FILL IN q�pqEu •���'S� W •
� Cr,r�ified'copy is filed wiih couniy n n 7�e• � ouuoivG ` �
r n de'rfinem. qoCaEss 24450 St. Ives Ct. p
Date� _App�iconi CITV • ZIP IOCAtiiV
'� C RTiFI �TE OF EXEMPTIO FROM KERS' '' �� " �' '" ' � - NO.OF BLDGS. � � �� NEAREST. ....... . . . . .. . ....... .. . .... ..._
'� COMFENSATION INSURANCE � � SiZE OF lOT NO\V ON LOT �RO55 ST.
(This'seclion need nat bo completr.d if Ihe permit is for onr, -� � - � � �� �� � �� �-�- ASSESSOR . � � •
hundred dollars(5100)or Ir.ss.) reneT ��425fi6 BIOCK I T � . 22 ' MAP pOOK� � PAGE PARC�L
o�;,h��lif. Communitics Inc No u5�zpN M✓+P
1 certi(y that in the performance oi the work(or which Ihis — /i I�� �� � � ' } I
permit is issucd,I sholl nor employ ony person in any manncr qe7aF55 3187 A Airwa Avenue � ��r' s`"ecini � a
so as�o become subject to ihe Workr.rs'CompCnso!ion Laws. � � � dflOOO COM1OITIOWS '�
Date � Applicanl ' • . . CIiY__.. .i1 a. z�P.92626 - ' .. . . , . . �
- �TICE TO APPLICANT:�If, olter moking Ihis Cerfifico�e o( ARCHIiECT CR TEL. — DiSfRiCT . GROUP iYPE FIRE . PRO[ESSED 9Y � I
mption, yOV ShOUId beCOme Subjett f0 Ih@ Wo�kefs' ENG�NEFR N / �pN$� ZONE V
�ompr.nsa�ion pro•isions of the lobor Code,you musl forth- ACCRE53J�JO WCSCCYL'•Pl ?�170. N.B. 92660 /� _R3 . � Nr W
wi�h comply wifh suth provisions or this pP�mif Sh011 bP' � IEL. STAfISTICAL C1A551FICATIpN APT. CONDp, �
deemed revoked. • � � CONTRACIOR NO. � .�/ ?
LICENSED CONTRACiO^.5 DECLARATION • � � � �i�, � � CtASS�NO. � ��w�i�UNITS__L_.!—
I hereby olhrm ihof I om I�censed under provisions of Chople.r 9 A��RE55 NO.
(commencinq wi�h Sec�ion 7000)of Di�lsion 3 oF ihe Business and .. , . , .___i��„ .. . ��'•�R�'wP �
Profr.ssions Code,ond my license is in full lorce and e�fect. Ciiv ClASS B 1 '" --- �" "' VALIDATION
, , _, T.Z NO.OF , NO.OF CHFCK �K. �'.
License Numbr,r liC.Clns STC4IE5�� FA�dNES 1 ONE . �
vawnrioN . _
Contract • � • Date - DESCRIPfIONOFWC7K .. . .... . A D�. . ❑ s 202, . . .- 1 GlI.7A' .
900.00 �
�I am ezem t under Sec. � � SFD�— PL1�N 4��� � �� �� � � �� .
.
ALTER � j:• • • •C�
B.BP. i r t 'S�C SOn . . RFPAIR � ..'_ ' ' ' -' ''
�SEOF � •5ca�o
.. D e:-�.. . . E%�S7iNG B�DG. DE!fOt ❑ . .
S���ai��e ' - _ .. arMicnNT �e� fINAL s •�.0('7 0�
oz,rvT� 714 Nc562-3700
OWNER-Bl I DEf DECLARATION DATE ( ,�^]- - �
�I hereby affirm ihal l am Empt(rom Ihe Contrncfor's Litensc . ._. . . '�J .. ., . ' l��.lJ��.(���.
law ior ihe following rr.a on(SeUion 7031.5,6�siness and ADC4F5 1. 2 FINAL '� � �
'Cr6fCssionSCcde):' � � ��-��-� � � � � '�'" � PRE N 0Y " ,��� �
--1 BU:LDING - . .. .. . .
� �, as owner of fhn prope�ly, or my employers wifh nDDaE55
.1 wnges os tti>�r�o!c compr.r.sa!ion,w�il do ihc work and , _-
ihe strucrurx is not inrenAed or oifered for sale(Section �aA�iTr :_� L��a .
7044,Bosiness and Prcfessions Code). � �' � M.OvinG � � � � ��� TEL �
..❑ .. CONiRA�'fOR ... . . NO . .. ,. " • • • � �
I,as owner of fhe prope�ty,am exclusively con�ractin� ��-� r.••
with licensr.d tontracfors to Conslruct ihe prajecl(Sr.c- ' ADDRE55
tion 70E4,Business and Professions Codr.). � '� � •�7 Jr 2,Q�
.. . RECuIREO. . IUTAI SEIBA(:K fltU.'A X��T. .. ... . ... .. . ...J V . .
CONSTRUCTION LENDING AGENCY � ' �����g YARD ���' PROP.LINE WiDiH �
1 he.re6y aflirm thot thr.re is a tonstrucfion lending agency for iHONi "' " "� �G��'
�the performance of the work!or whith this permit is issued � P.(. - � e y,�.5_II�
(Se[.9097,Civ.C.). SIDE .
. . . P.L. ' • _ � .
Le!nder's Name
.` /J ( lD.ti1A keF.k ,
Lendcr's Address � � � P.C.Foe E ��Q��v ' permn Fee ��} �•U� , . .
- I certify Ihat I hav Ihis applitatian ond siare ihot�he . .- /�� 7S�l�' issuance Iee �—� �DMA P/C�" •
above informotio is correc I ogreo lo comply wilh all Counly lnvesrigo�ion Fee
ordin ces and lole � to build�nc�conStrvCtion, . , .. . __... _ -. To�al Fee .��i I�.'dA Pnrm.M- - � - �
d he eby null epre ntative of Ihis Counly to enler �
n t ab ve. r.ntianr.d roper i r inspectio r,,.Po��. .._. ._ .- . - - -. . .. . ..�'bty3i�3S . .. . . � � . � .
...
�>
$ 2 SEE REVERSE fOR ExPLANATOiY IANGUAGE
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