HomeMy WebLinkAbout1643A 1644A . ... . ... . .. . . .... .. ..._. _. . ._ ._.. .. . ,
WORKERS'COI'dPENSATION DECIARATION � ' " �� � . ' �
�
I he�eby offirm�hol I have a certiFica�e of consent io eelf
... ..._........ . . . . .. .
,�S��P,o.a�f�,,�,«�eofWa�ke�=-�omP��,o�,o���s�.a�«, APPLICATI�QN FOR BUILDING PERMIT
or o cerr(�ed cop'y+hereo((Sec.3800,�ab.C.) COUN7Y OF LOS ANGELES BUILDING AND SAFETY '
Poi;�yN�C 860-755(omP�;1aU5 Inder:nitv Co.
� Cer�ified copy�s hrreby furn�shed. � FOR APPUCANi TO FILL IN eunoinG �a �� • ��� � �
ADD4ESS
� Certificd copy is iiled wit �he oumy nq ins c • BURD:NG (
r de� rlmenl. ADDRESS 24453 St. Ives Ct., ,�� � ,
Dnle� Applimnt _� GTY ' ZiP LOG4LITY
�NO.OF BIDGS... . . . fvEARESi. ...�. .. . . ... . .... .. .
� � C RTIFIC TE OF EXEMPTION FROM KERS' " ��" ' "' �� �
OWIPENSATION INSURANCE • • 512E OF LOf NOYJ ON LOT CROSS 5T..
(This section need not be completed if Ihe p.rmil is fo�one � - ASSESSOR
.hundred dolla�s(SI00)o��es5.) TRacr ���42566 !lLOCK L f 19 /.Mp yppK� PAGE PARCEL
E. USE ZC!�E NOP I �^ �Y'1
I ceriify ihot in the perFormance of iha work fnr which this ntivh �� - ,� }
permit is issued,I sholl nol employ ony person in any monner . 31H��A A�rW1 nAvenue . Rn_� SPECIAL � � -� � � O. �
so as to become subjr.ct to Ihe Workeri Compensalion Laws. ADDRESS� y �L[JO O c1 CONDITIONS �Q
V
•-- . . arv .. Costa TIes1. . zia_92626 . .. . ' . ��
Dalc � � ' � Applicont ARCHITEC70R 1FL. DISTRICT G40UP 1YPE FIPE P40CFSSEUBY �
�TICE TO APPLICANT: If, aficr'moking ihis Certifico�e of CONST. I E r'j I
mplion,�y0U ShOUId he[Omp Subje[f f0 Ihe WOrkPri � ENGIhEER NO. - �
�Ompensolion provi3ions o(1hr,Iober Cnda,you m�isf fnrth- ADDwE�9�O S�.TCSCL'IZ}� P�. l�1�� N.�. 92660 �a �"3 �W
ilh comply with such provisions or Ihis permit shall be� � � � Z
deemed�evaked. � TE�� SfATISTICAL QASSIFICATION APT. CNDO.
COMRACTCR 1 Q 3S Owner NO.
UCENSED CONiRACTORS CECIARATION � � �� - � i��, aA55 NO.�Dw�Li.UNiiS
I hereby alfirm that I om licensed unde.r provisions of Choprer 9 nDCe[55 no. � 393701
SElY:R MAP
(commencing wiih Sea�on 7000)oF D��islon 3 oF�he 8ustness and _ . ... . �i�. .. .
Profe:sions Code,and my license is in full forcc nnd r.fieU. - CLn55 B1 � 6C. �G. ' � VALID 7
' .(T. NO.OF NO.OF CNECK .
LicenseNumber 393701 ���,Closi R1 60) S70R�E5 Z FA�!ILIES 1 on�e �
/��� Q�n 7� VALUAiION .. � I�• • � •2
COontr6crc� . . Date�,�y�y CESCQIPf�C4 OF V.'ORK " L = , . '.
� � ADD � 202 90�.00 � •5 0 Q 7 0 ..
I am e.emp undnr Sec. � - ' " " - " - � '
SND — YLAN 4 - .. airtR ❑ s • e"G�7 U;
B.BP. f �h� rea5 n .. REPAIR.� . ... . . .
' D e: " USE OF DE:'OL ❑ ��.�5��6 �
EZ15TING BLDG. -
$it�nfl�Uf � AF�F NTI 714;;0.662-3700 FINAI . .
O\4NER-6U ER ECLARATION -DATE� �vZ�-�C.-� � � --��- � �� � -��
�-I he�eb afFirm�hal I am e m t from�he Conhoctor'S License . . . . . � �
Low fa�lhe followinq re.as n(Setlion 70J1.5, BuSinCSS Ond nDDRES�IH7A AlIW1 e�1VE.'. C.ii. 92626 F�NAL � • �
"�ProfcisionsCadej: � ' ' " � 'rw ni 0Y C�, � . .
� BUILD:NG .
I, as owncr of thn prope.rly, or my nmployees with AC�vESS :':�.0 C.�1��
, �1 wcges os Iheir sole compensation,will e1a the work and ��A��TY � "
th�shucru�e is nor intended or oficred for salrt(SeUion , , . e • . .��
704A,Buslness and Professions Code). -� PnOv�NG ' - ttL ' '—� __ ' , '
CCNTRACTCR h0. J��" ��' �
�. ..: ...
I,as ownr.r of Ihe proper�y,am exdusively conrroUing .. ...: , �:.. ..-'__�:.� '.�� •8 5 2 G 0
�-� with licensed contracbrs ro mnslrucf the projecl�Seo �� � ADDRE55 �
tion 7044,8usine.ss nnd Professians Codn.). • e�;���•Q v
REUUIRED . IUTA�SiT9ACK iRJM x� . . . . . .
'-� ` ' CONSTRUCTION LFNDING AGENCY ����� � �-� Sk�enCK YARD HWY CR07.IINE wioiti
I here6y affirm ihat there is a cans�ruclion lending agency!or �pUNf _:,tti:"�.':' � . � •:.t. �C.l�i"8 b '
�he performance oi thr.work for which�h�s perm+��rissued � � a L. � - - ��� � � - ` - �
(Sec.3097,Civ.C.). Sioe � . � �
.
.. . .... . . . .. . P.L. . . . .
.. . .. .... . . . . . ... ..
Lendcr's Name. ' � .
� � � � � � � - � P.C.Fce S SD O. � LD":A Ref.M '
Lender's Address - (� � Pe.m��Fee� f.� ,
I ceriiFy ihat I havo read this applicaiion and stote iha�rhr. . ,A' �/•.5��- iss��re fee �- Q•�� LDMA P/C X , � ��� �-� �
abpve infarma�ion' corre . agrc�fo camply wilh all Counly Invesnqo��on Fee Q
ordin cr.s and 5 te 'ng�o bu�ld�ng co�siruci�on, .._ � �
n he eby utho'e rep� o ounly lo nnfr.r ��� � �� � To�al Fee�- VS� � I�!AA Perm.M� , � •
p �1� ob vc- ' ad pr erfy or ins .tio purpos s. _ y�_._ L�3� . �.-
� ' ._. .. .... . .. 0��„��� ... .. .. . . . .
0 SEE REyERSE FOR EXPIANATONY LANGLIAGE
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