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HomeMy WebLinkAbout0888A 0889A � . , . _ . . . . ... _. . .__ _ __._..___ ._ . . . .._ ._. _ _ WORKERS'COMPENSATION DECIARATION ��'� � ' �� •- '' �' , Z . . . � _._...... � _ � I hereby oFF,�m thot I have a�e�,;t,�a,e of�o�se�„o,e�f ���qpp���ATION� FOR-.BUILDI NG��PERMIT -��� insure,or o certificale of Workers'Compensaiion Insuronce, . _. , or o certiticd copy�hereo((Sec.3800;La6.C.J� � - �� �' � � 61WETX7993 Hartford'Group GOUNTY OF LOS ANGELES BUILDING AND SAFETY � � PolicyNo. Company BUIIDING n }� / Q �Cerrified mpy is hereby furniihed. �. . . � fOR APPLICANT TO FIL!IN ADDRE55 '�G 3 L. �z� � Certified copy is filed wifh tfie�ounly build'ng indpec--' � BULLoiNG � . ro�de imen � ADDRESS 24437 East Thunder Trail b ' ` Diamond Bar— .._.... Da1e' � �1PPIitaM G � UTY ZIV IOGLIiY � '' CERTIFICATE OF EXEMPTIO FROM WORKERS' �„ � � ��� � � - NO:OF B�DGS. - --� � �- NEAREST ' � � � COMPENSATION INSURANCE' � �� SRE OF LOi NOW ON tOi CRO55 ST. � (TBis detlion need no�be completed if the permif is for o�e � 72ACT 4Z�JFIH 'J BIOCK LOi NO. /, NAP BO�K'� � - PAGE PARCFI .hundred dollars(5100)or less.) .. ..,. -. ,, TEL. ) .� • ... �•,.. .. . ... .- OWNER � BY'a�ll " �111� NO: ��� E �P ' �l�� I cer�ify that�in lh'e performance oi the work fo.which�his ��� �� > permil is issued,I sholl nol employ any person in any monner _ _ SPEGP.L --- �- - - � - O- so'oe to become'subject to the Wo�kers'Campensalion Laws. nDORE55 Od� CONDITIONS '� V �.. � arr zia . � Date ��' � ' ' APPlimnl� ., , ..., . "� I �'(ICE TO APPLICANT:�If, aifer�moking-�his Certificdle of A�HITEC TE�� DiS7RICT GROUP ttPE._� FiRE PROCESSED BY � 1np�ion, yov should 6ecoma subject to �he Workers' �� ENGMEER NO. - COry �!�E ~ Compensofion provisions of fhe Lobo�Code,-you mvsl forlh• qDDRE55 3990 Westerl Pl SU7 t2 ��� �� - -J . �.Y^ a wiffl COmP�y w��h Su[h provi5ioni or ihis pe�mit sholl be- 7E1. STATISTICAL CLASSIFICATiON APT. CON00. � deemed revoked. � .� � CONiRnCiOit � NO. - �L Z UCENSED CONTRACTORS DEQARATION- �'� � � � - �i�, - ��CtASS NO.��-� � DWEtt.UNRS �T / I herc6y offirm that 1 am licensed�nder prov�sio�s of Chapeer 9 noozess ��3151 Ai rwa Ave. N No. 40961� gy,�R�qP (mmmencing with Setlion 7000)of Division 3 01 ihe Bosiness ond . . _ _ .. ._ .p�.... . � FroFessions Code,ond my license is in fuil foice and e(fetl. Ctiv C1A55 "' BK- -- �' �" - YAII�ATION -' � ' ' ' Sq.FT. NO.OF NO.OF CMECK ' � _ �licenseNomber 409610 i��.�C�ass� ' B - size sroeies FAMIUES - ONE � � � /�jc/ / v�wanoN �^ ;�C 8 Q 8 A ' . . . .. DESCRIPTI�.JOFM/ORK . ../ .. N� 11� CJO� � Confraclor � � Dale ADD � s l ;;o • o .2� �I om e•empl under Sec. � - S 1 fl �Q F8�111� .R251 d@�1CL -- - ALTER � ��, w��� . s I •�4a6c I B.BP.C.for fhis reason _ REPAIR.� � -�- � �"- : � � � Dale: USF OF DEMOI 0 ' °J�� :.��v E%ISTING BLDG. � I Signolure ` APttica.NT �e�. . FINAL _ ' _. _ O�2 O�E b 0 NER-BUILDERDECLARATI vRiNT Geor e Vedell NO. S5�-�OO�'� ..DATE I hareby affirm Ihat I am exempt from�he Con�roclor'a License qDocE55 l 1 Ai r A fIHAC � �� law Sor�he following reason(Seciion 7091.5,Business ond 7 _ _ . __ Professions CodeJ: - ' � " �- " - ' aR N dy �� � • , � . BUILD'NG ' , . __. _ . ... 1, os owner oi ihe properiy, or my employees w�ih ADORESs wages os their sole mmpensation,will do ihe work and � :-Q��G�i H . �he structure is not inlended o+oifered for sate(Section ��`t�TM . . ' 7044,Business and Professions Code).' ' � -- MOVING � ' �" " " ��� �� TEt. � ' " �'� "- . � ' �F b"e • c e � �, I � 1,as owner ot the prope�ty,am exdusively tonkacting CONTRACTOR NO. . . ... � , . -wiih licensed coMroctors fo[onstruct Ihe pro�eU�Se[• qDORE55 � °:G�'�G I �ion 7044,Bueiness and Pwfessions Code). .. � : � .QEQIIIRED IUTAL SEIOACK F M.. . 1 „�{'j.4..I� S �CONSTRUCTION LENDING AGENCY SEi BACK ��ARD �HWY PROP.LME N/IDiH ��n� �. I hereby offirm fhaf there is a conshutfion lending agenry for FRONT - - �. �, • " . • � . . . •.. '• �,� .,_^ -tha periormonce of ihe work(or which�his permd is�ssued --- -P.l.�-�-� �-�- -�� � - - � ---�--- ----- �- --�--"" '� " ��•: C� C�-- {Sec.3097,Civ.C.). SiDE ' ,, � Toronto Dominion Bank - "- ``' - - � - -- �-'- � - Lender's Nome �J 7 -7 (�' IDMA Ref.k , : � ' a 144 Sansome St.p �Lll te �OO . ._, p,[,Fee f- .! J'��- Perm��Fee �� /'J V- - -- _ , , = lender's Address • � ' �� i + �1 l0•� .. � ; � I.certify thoi I hove read ihis opplication ond sia�e ihot tha . .. ... . _ ./S�� -- iesuence Fea� � - - -- iDMA P/C M- .� - '. �. � � ¢ obove iniormalion is corred.I agree 10 comply wilh all Coony invxsrgauon fee :1 . . . ' g ordinancee ond Slale laws relaiing to building consiruction, _ io�ol Fee--�SS D`�� - IDMq Perm.X � -� , . , . � and hereby o�ihorize�epiesen�a�ives of this Counly�o en�er �� � upon fhe above-men�one prop t !or Inspection pvrposes. . .. . _ .. � . � _ . _ _. - 3s=---= a' " � � SEE REyERSE fOR EXPLANATORY LANCUAGE ,-'=� � ' .4� , ' ,_ ' . .„ . , ^ -�----����� t e . .�. _ ....._ ._. _.. __ ._..._- � -- - - - ... ..' -- .- . . -_' . \ - - .._ ' _� �._ Oi � � � ,, � o o • � �. -�' '� '• O �.-o` � o Q ? .n =r o i-N I t�0 4 �'p 7 '�O � � 41 0 . .�O �!O„ O� �N �. i9 O �D ^ ` . � �O 0 O d fp �p p A a R + , y2 t1 � tp O �9 ' O � � " .1 r Tr � O � O � � � O �u Z � ; o � �o � � �=�:_ �; 0 9 � � � � a � � �o �� . ° p v ,. o m 0 0 �` \ o � !. � 1 O ? �p W O Q° �p r� • . „C �p . � (i • �7 � � ? %� -� �, Q ~ � i y Q � 1�Z �Q n,� x �4 C a ' L' r ° p, ..� � `, ` � R°� `^ � � ° ,� d � M o�6 ° � � �� Z' o I� ` o "� ?. a S t� o . 0 � t� �'~ ;�` � o � . 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