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HomeMy WebLinkAbout1052A 1053A � WORKERS'COMPENSATION DECLARATION �� � "�� � -� - - '-� ' .._. � . . . .�. . . .. . . . I hereby affirm,]hat I hove a certificate•of conseni to self APPLICATIO�N FOR .BUIL.DING. PERMIT � � insure�or a cer�rimte of Workers'Compensalion Insurance, or a ceriified copy ihereof(Sec.3800,Lab.C.) � '� ����- `��� � � � � � � �� � . ��G7C005-279��� Natiornaide, 60 B 3 car COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy y - " ' ❑ BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN qppRE55 2�?370 E. S lvan Glen Itoad � Certified copy is filed with the<oumy building inspeo- BUIL�WG tion department. ADDRESS 2�370 E. �. Date 5-14-86 Applicant Tf3E.AA7DECV GROUP aTv D].ainOTKI BaY' ziP 9176 �ocnuTv Dianwrd Bar CERTIFICATE OF EXEMPTION FROM WORKERS' � � NO.OF B��GS. NE4REST . COMPENSATION INSURANCE SIZE OF lOT NOW ON LOi CRO55 ST. (This seclion need not be completed if the permit is for one 7RACT � 'ar-..w����������dLOCK ,W�P BOOK PAGE PARCEL hundred dollors(5.100)or less.) TEL. USE ZONE NtAF ry� I certify rhat in the performance of the work for which this OWNER TI'� ��l NO. — �_j Np, . mc ��..�� y permit is issued,I shall not emplay tlny person in any manner SPECIAL d so�as to become s�bject to ihe Workers'Compensafion Laws. NDDRESS ��7� CONDITIONS V .. GTV �Ul�. ZIP _��.?2� OC �e Applicant ARCHITECT TEL. O ITICE TO APPLICANT: If, after making ihis CerYificate of ENGINEER D�STRIQ GR9UP NPE FIRE PROCESSED BY b.. Ve Szan AIA No. 445-4 73 c T. � V +,,,.,,.pption, you should become subject to the Workers' �p q � � yd Compensation provisions of ihe Labor Code,you must torth- qODRE55 314 N, T�']Y'S't� �' Arcadi.a 91006 �� Vl—� /.-1V � y wifh comply with such provisions or this permit sholl be � ' yEL. STATISTICAL CLPSSIFICATION APT. CONDO. a deemed.revoked. CONTRACTOR �� �IN G�QL� No. � LICENSED CONTRACTORS DECLARATION �i�, CLASS NO. ��� DWEII,UNITS �� I hereby affirm ihot I am licensed under provisions of Chapler 9 ADDRESS �$ c'1�.7pV2 NO. 371 8 SEWER MAP � (commencing with Secfion 7000)of Division 3 of Ihe Business and __ LIC. Professions Code,and my license is in f�ll force and effect. CiTY CLA55 B BK � VALIDATION � � � S�.FT. NO OF NO.OF CHECK L�, n r,��, License Number 371580 ��c Class $' SIZE 2375 S10RIE5 FAMIUES�- ONE �r • � Rl�]DE[�T GROUP 6—Zp—$E DESCRIPTION OF WORK S111Q12 fdIP.11 NEW � �'°`�UATION s C i ;':�a ¢ Coniractor pote App ❑ $ � .'$��Fj80 �I am exempt under Sec. � , � ��`�����9 ALTER B.&P.C.for this reoson REPAIR � S °� `�-�%�a•�= > — � Dafe: USE OF DEMOL E%ISTING BLDG. � ��i.G[—�&� Signature APP PR NT) � ��� G�� NO. FINAL OWNER-BUILDER DECLARATION � Ve , , . DATE (Z��F'`$` I hereby affirm fhat I am ezempt from the Contmctor's License w for ihe following reason(Section 7031.5, Business and ADDRESS FINAL " ,£essions Code): �� � PRESEM BY � I, as owner of fhe ro erl y P Y BUILDING _,,� p p p y,,or m em lo ees wifh ADDRESS s� �,��W,� �'—'�"' wages as their sole compensation,will do the work and the slrucPure is not intended or offered for sale(Section LOCAU7Y ' h r , M � � ." 704d,Business and Professions Cade). MOVING� ' TEL � �� ����-' ---�- - � "-' � � � I,as owner of Ihe property,am exdusively coniracfing COMRACTOR NO. i �,,�4,`�;�,`� ....__. .. ... ., with licensed conirattors to construct the projetl(Sec- qDDRE55 tion 7044,Business and Professions Code). � � � r, �;�R G V,��? CONSTRUCTION LENDING AGENCY RE�UIRED yqRD HWV TOTAL SEtBACK FR M I . - - . ' , SET BACK PROP.LINE WIDTH I hereby affirm thot there is a construction lending agency for FRONT - �1�.C-�""�`O S the performance of ihe work for which ihis permit is issued P.�. � —' � � - (Sec 3097,Civ.C.). SIDE • Lender's Name COY2t].I72Iltcl.l I111YYJ1S P'L � " • 231 S. L�Salle Chica IL P.c.Fee s 334.69 ae,m��Fee 478.50 �DMA Ref.# , - — Lender's Address � - � I certify that 1 have reod this application and state tha��693 �u�a��e Fee - 1�•50 LDMA P/C# , - - ¢ above informati � correct.I ogree to mmply with all County Invesrigation Fee s ordinances a S te laws relating to building construction, . Total fee �F89.�� .LDMAPerm.# - � - "'� and hereb au e epresentatives of this Coumy to enter � upon - ed property for inspecti urp ses. $7F - -.. �. .53�.�' �I (�/ J a �+ C�(.7 LDM�EE REVERSEfOR EXPIANATORY LANGUXc,c� . ^" , Signature of Applicanr or Agem Da�e . . . - . .-...' 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