HomeMy WebLinkAbout1659A 1660A (9) ., . . .... . ... . .. ._.. __......... ._. ... --. .._. . . .---. _. . .. ...
YlORKERS'COMPENSATION DECLARATION ��� :� �'� ' . � " . ' : z'
;�;�:eho�a"�P„i��,�o�wok�:-'�om'P��o�o�°��;��o�«` � APPLICATION FOR BUILDING PERMIT � �
or a cr.r�iffr.d copy�hereof�Sec.3e00,Lnb.C.) COUNTY OF LO$ANGELES BUILDING AND SAFETY ,
Pol�cyN3',� 860-7556ompaF,qt��S Indemnity Co. 'r
� Cenificd copy ts hcrcby furnishr.d. � FOR APPLICANT TO FILL IN ADDRE55 }r�Co i � / �.
� Cerlificd copy is fileil wiih ihe oun y bui p. - gu!�D�NG
r� n deP rtmenf.' ADDaE55 24G56 St. Ives Ct. �•��
,. . ,
Date� Ap�licont CITY ZiP LOG4LITY '
RTIFI ATE OF FXEMPTION ROM W KERS� ' ' ' ' ''' ' NO.OF EIDGS: "" ' NEARfST ._ . . . . .. . .. .
' � COMPENSATION INSl1RANCE ' ' Si7E OF lOT NO�V CN LOi CROSS ST. •
(This seclion nr.rd nol 6e compleled if Ihr.�e.rmil is for one � ��-- ��- ��� - n55E5SOR '
hundrr.d dollors�5100)or less.) TRACT �yZSE76 EiLbCK T NO. 21 MAP BOCC PAGE PARQL
. . . " OWN" .. . ,- . ' ' NO...... � U•\f=iJ �? II� .!�
I tertify lhaf in Ihe periormance oi the work ior which Ihis . � I
permit is issucd,I sholl noi employ any person in ony manner � . . ._ - sPEaA� � . , �.a
so as to br.come subjn,cl to 1hr.Workers'Compr.nsaiion Laws. ADDaE55 3187�A Airway �venue� o�,�� CONDITiONS 0
, . . V
aTr Costa Mes1 .. zir.92626 . ne
Daie ' � ApPlicanl ' ' I
• �rICE TO APPIICANT:�If, ofle� making �his Ce�����cate of A�kiITECT OR TE�� � DISiR!CT GROUP ttPE . FiRE . PROCESSED OY �
� �.o� FNGIhfFR N CO ZCNE W
p , yoo shoo�d become SVIIj@CI io�ihe Workers'
�.umpensation p�ovisions of Ihe,lobo�Code,you musf forfh- qCp�Es�990 Westerl PL £E1�0, N.II. 92660 �v �' . . � . a
wilh comply wi�h such provisions o� �his�e�mil Sholl br, � TEI. $TATISTI�,4�CIASS'FIC�+TION A�T. COIv�O. �2
deemed�evoked: . � � � CONienCTOR 0 e No. .�f .. —
LICENSED CONTRACTORS DfCL�RATION ��- - � ii�,� � Qa55 NO. � ���u.UnliiS_L
I herr.by afii�m Ihal I am litensed under provi5io�5 of Chapter 9 ADDRE55 Np. ��R�P .
(commencing wi!h Seciion 7000)o(Divis�on 3 of the Business and . . . . . . . �i�_ . .
..
Professions Code,and my license is in foll force ond effecL CiiV Ctn55 � ' �er ""��:. " " � � VALIDATION
� 50� 1 NO.OF h0.CF CNECK ' �
license Numf:er � LiG Clos S�Z STO41E5 Z iqM.!LIES 1 ONE � ;:'� J��j��
vAwarioN
ConlroUc '. � �Dnte � DESCRiDTION OF W02K ' A D ❑ S 1 Z O . �F • •.•2, ....
�I am e.empt under Set. �" ' � " � , ( •L;(?,�?) � .
SPD — YLAN 3 ALTER
B.SP.C. r Ihis easoS .. __ RC7AIR � . .s. . � ' ' • •�j f',L,�'.�� •
� USE OF
� ���P FXISTING FIDG. DFMpL ❑ . . ,
sq�vrure - nee�ienNr Tei FINAL G`!�5—B 6
OWNER-BU ER ECLnRATION IFRivi �I�W(.C762-3�00 _DATE�
I hereby oflirm thot I om e pt irom Iha Contracior i License J�G'� , , ,
� Law for fhr,following reason(Section 7031.5,Business and ADDRES 18 A Airwav Ave. C.M. 92626 FINAL
Pro(ess�ons Codr,): . . . . . . - . - � paEseh� ��BY �LV � � � . �
�-7 BUILC�NG
` I, os owner oi thr�roperly, or my employees wilh nDDRE55 . _ , ':�,� .
� wag�s as thcir solc compensotion,will do�he work ond ' .� � (�(a Q l�
Ihr.structure is not intendr.d or offered for sale(Se.c�ion tocnun .
70A4,Business nnd Professians Codr.). � � MOViNG � � - �' TFt: ��- _ , , 1 • e�e . � '
.r{ CONTRARO4 _ . . . .NO . . .. . - .. ... '_ .. ��' � .
�J I,as owner o(ihe properfy,am e.clusivr.�y contracfin�
wirh licensed conlrattars to conslruct Ihe prolecl(Sec- � °r!2 C'U
tion 7044,Business and Prolessions Coda). �DDRE55 .,
. RFOUIRFU YARD fiYN IUTALSCi7ACKlRG.•.1 Xi i. _ .. ..._ . . . . . . b.r��n..�+. —.. '
CONSTRUCTION LENDING AGENCY SEI BACK PNOP.LItiE N'iDiH •L r..U 7 u
I hereby of(irm ihat�hcrr.is a tonstruUion lending ogency 1or FkONI ' '
�he pr.rformance of ihe work for which�hie permit is issved � � -�a.t. - � � � � ' � � �- '� � � � �-C Q C v�p F �
(Sr.c.3097,Civ.C.). SIDE , ,
. . . . P.L. .. -. - .. . � ' ' '
Lendcr's Namc p r (� .
6�•6 S� LDA1!\Ref.M '
. � P.C.Fee S � Pmmir Fon . . a I rS� '. ... �.� ... . _. _ .
Lendcr's Address y�
I cer�iiy that I have read this application and smte�ha�ihe ... C/-8�� ..�S'� � I:sua�ca Fr� . �b•S� lD4W P/C M . � . .. .
.
above in(ormotion is co.rec�.I o�rea io comply with all County i,,,,�sr�garon tee q v , � .
o.dino ces ond �e relpiinc�io building construcfion, _... ... � To�nl fee �- �+��'O LDMA Perm.M � �
n her by aui IP . IO i of�his County to emer �� • " � � �� ,
Ih+!ob ve• tionf!d pr perly f r inspect n pur oses. �- '
. .. . .. . . _ . . .. . _. . . . . . . . . . ..
�� ,�'y� SEE REYFRSE FOR EXPLANA70RY UINGUA������� .
ignoN of Applironf or Agent � " pafe .- . . ..-.. .. '. .�I
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