HomeMy WebLinkAbout1645A 1646A (9) . . . , . __ . . .. .._.. . .
WORKERS'COM.PENSATION DECLARATION . . '..-'.';.....�,_ _. .. .. . .. ........ . ... ...__. . .... _ ... . - .. . _ . . ..
„ehY nffirm�ho�1 have a�e,,,F,��,�of���,e�„o,��� - � -- APPLICATI�QN:. FOR-�BUILDING PERMIT �
�rr„or a ceriifica�r.of Worke.s'Compenso�ion Insurnnce, . , ,
i ceriified cepy�hr.reof(S�t.3800,Lnb.C.) . . " . .
COUNTY OF LOS ANGELES BUILDING AND SAFETY
cyNo.EC RF,(1-75§(�,pan�ndnc Tndrmnitv Co ' ' ' ' p,�
Cerii(ied cepy�s hereby 4urnished. , FOR APPLICANT TO F,ILL IN •. noca[ss ���ZI l�'�• `ea� � - .
Cr.rtified copy is filed wi h t co�nf �ng insp.• BUILDING
i� ndep rfmr.nl. � ADDRFSS 24459 St.�Ives. Ct. . � �_ �•
�/} _ � • _.
, .. .
,=C� � 'Applicont --� CITY • ZIP LOULITY
RTIFIC TE OF EXEMPTION FROM ORKERS' � '� � � '' ' � NO.OF RtDGS: � � n�EAReSf �
_.-....... . . . .. . . .:
' OM.FENSATION INSURAN � SIZE OF LOT NOW ON LOi CROSS ST. �
+s sec�ion nr.ed not be mmpleted if the pr.rmit is for one � --� � -- - n55E55oR
�dred doilars(5100)or Icss.J � • TRACT lyZ (7 RLOCK L T 'O. 2� � MAP ROOK � � PAGE PARCTI
ov,,NC,�11if Cor.mmunities,- Inc N� 62-3700 u.s��o� M�W ff��.�
�rtify thal in 7hr.performance of Ihe work ior whith this �� N0� ' !� I
mil is issucd,I shall not employ any�erson in any monnr.r ..... ���RESS 3187 A Airwa Avenue � . �vo�j SPECIAL� � , �a
�s�0 6r.comc subject�o ihc Workcrs'Compr.nsa�ion Laws. � CCti�iTiOvS �
. � . . V
e � APplitanl �. �. . .• , . CITY. . . .ZIP 267.6 _ . ... . .. . . . m
TICE�TO APPLIG4NT: IF, ofler moking this Gcrlificole o( ARCHITECTOR TEI. DIS�RICT GROUP TVFE fIRE FROCESSFDBV O I
Fnption, yo� should become subjecl to Ihn Workers' �� ENGihEER N _ CO• ZONE ()
r�F�s�ro��,�o��+�o�:or rtiP�abo�codP,yo�m�:r�o�ih- noo�e:3990 k'esterl Pl i`170,N.I3. 92660 �D /�-3 � `J� �
h camply with such provisions o� this pr.rmit shall be � �
!mcd rCvok2d. � ' , TE�� STATISiI�P.I QASSIFICATIpN APT. CO!.DO. .Z
CONTRACTOR NO. ..}—
LICENSED CONTRACT025 DECLARATION � � ��-�� � ��-- �i�. �� �CLnSS NO.� �� CvhLL.un;�TS I
±rr.by offlrm�hat I am litensed undr.r provisions oi Chap�er 9 ADCee55 �;0.393701�
mmr.ncing wi•h Section 7000)of Division 3 ef the Business and . , _, , , ��� SEW:R�lAP
�fessions Code,and my licensr,is in full force and eficcL CIA55 BL ,K.' - � --' " ' ' VALIDATION
� _ .f�. NO.Of NO.OF CHECK • .
ensc Number Lic.Clnss � � STOR•ES fA!u!iLiES ONE ��• .
� VAIUATION . ;� �(I,v�1 .
. . �i -� CEXR�PTIOY OF WORK -. ..... .. .... �CW �
Nmctor Date V �'
� SFD — PLAv 4 noo � s , .. ;;• • • •2�
I am exem nder$ec. �
ALTCR
�.BP.C. 0 lhis eosan . .. REPAiR � s " I�°F O 0.7 O
ie: USE OF �E.V.C: ❑ ' • •L'�,�� /G� .
ExiSTiNG BIDG. �
' Si�nature '- nvPtiUNT TF�. FINAL � . . C
OWN R-BU bER EQNRATION �R:Ni� 714�0.G62-3700 , pATE. ,������7 � � 0 5-�b �
�e•eby affirm�ho�I om e mpt from the Conlractor's License , „, , , � . ,
iw for 1he following reason(Section 7031.5, Business and ADD4FS5 FINAL ' � �
ofessionsCode): -- " � vwt ch 0Y ��.�„� � � � � �
1 BUIIDING
` I, as owner oi ihA properly, or my employrtos with ADCaF55 , _ - • _ ,_ • • '
,/ wages as Iheir sole compensation,will do�he work and _ `_�i :�'G.�J 11 ,
� the s�ruclure is nal intended oroflered for sale(Section ����TY '
7044,Business and Profr.ssions Codr.). - M1'.OViNG TEL. ' �� � � � __ �' ; f j.• a a • • � �'
� 1,as owner of the property,am exclusively conrrocting CCNTRACfOR ' h0. , ` _
wilh licensed tonfractors to conslruct thr,projett(Sec- ' � qpC4E55 . r "�G?'G� �
tion 7044,Busincu and Proicssions Codc�. ' � �
.. .kFOU:RED YAR� H\VY iUiAL SEi[inCn .SA xi i . . . , • �L�j 7 L J�,
CONSTRUCTIDN LENDING AGENCY � SEI BnCK PROP.IINE wiU�ii
hereby aifirm ihar ihere is o conshuction lending agency for f NUNI �C�O��£)� '
he performoncc of�he work for which this{fermil is issucd P.L. � � � � �
$CC.3097,Civ.C.). SIDE ' �
D.L. . .. ' • � .
Lendcr's Name .
�C� p LD.MA Rrf.d �
lendcr's Address �' P.C.Fee S v���7� Pmm�i Fee�� p •�1�
I ceniiy thot I hav ihis application and state ihat�he 7��� i„u��ce Fee ��� .IDMA P/C M ' � �
obove informaii is corr t.I agree to tomply with all County invev�ganon Fcc `p � '
o�d� ces ond 5� to building tonslrutlion, Taal Fnn� p J�.�� �(DMA Perm.#
n hn eby au ori re rt!5nntnlives oF�his Counly to enter
n t 1 v.m.nlio ed pro erty r inspr.ctian urposcs �/���� � �
� Qj ,—p/") SFE NEVFRSE fOR EXPLANATORY IANGUAGE � � .
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