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HomeMy WebLinkAbout0613A 0614A (6) _. .__. �. _... ,�(,o L � '' WORKERS'COMPENSATION DECLARATION P,1�1,p j}], � ��' ""'�"-' """' � � :�� ` ; I hereby off,rm rhq�I have a certificate of consant to:elf $],eV: B qpp��CATION ��OR BUiLDING PERM�T � inswe,or o ce��ificate of Workers'Compensa�ion Insurance, or a certified ca y lhereof Smc.3800,tob.C.) � �3—CK-94�—�04 �PA Aetr�a � COUNTY OF LOS ANGELES BUILDING AND SAFETY PO kyNo.��- o�Pa^Y- BVIID�NG � �Certified copy ie•hereby F,.o�shed.�� . FOR APPLICANT TO FIIL IN qDpRE55 24337 Vista Buena L7rive C6rtified copy is_fi�ed with the county building inspec- BUILDING titln departmEnf. ADDRESS �� 5/29/85 _ TH�.ANDEN GROUP Dale RppliCanf' CI1Y 1 ZIV LOUIITY D�Ild �r CERTIFICATE OF EXEMPT�OM FROM WORKERS' " - � ���e�as_ r�utEsr - � � - COMPENSATION INSURANCE�� � 51����T ���OT CR065 57. � 10 & .GOI.CjPII S lri S (This sectfon need not be complBtecl if the permit b�fOr one T�R 42584 v BIOCK lOT NO. �4 /a,qp�R •" pq� pA� hundred dollws(Y100`or lass.) . � IEL. USE ZONE I cerrify that in the performonte of the work for whith ihis OWNER - Np. - pp, .2.O� } permit is issued,I-shal�not employ any person in any manne� 10.74 Park View Drive -I�-1 �IA� d so'os io betane su6ject to ihe Wor�Compenwlion Laws. A�E� � CONDITIONS u Dare � ApPlicant ' atr COV1Ild Ziv 9�-722 � pq ARCHITECT OR IEL. � '�;CE TO APPEICANT:�lf,'afier makinq this Cerfi{i[ate o1 ENGINEER rro:445-40 3 DISTRICi GROUP T'YpE FIRE PROCF$$Epgy ,�_, tnption,-yod should bewme subject to the Wwkers' �j T. Zon�E Coinpensmion provisions ot fhe la6or Code,�yoo muat fonh- qppREss �d "`3 �'7r w �::�w.lth comply�with such prpuisions w this permit shpll be TEL. STATISi1CAL CtA551FICqiION �� � naf. CON00. Z ' daemed revoked. . . . CONTRACTOR Np. �.�r� � LICENSED CONTRACTORS DECLARATION - - � -� - ��,�� � � � �CkA55 NO. ��+V �DwHt.l7NlT5 t� i hecaby otFirm fhat i am(icensed under provisions of Ctwpter 9 ADDRESS ryp, (commencing w71F�Secfion 700D)of Divisiort 3 of!he Business ond . - LK. SEWFR MAP , Prnfesaions Code,and my licenae is in fuil force artd efEecL CItV Cu55 B BK. �. VqLIppT10N ! Sh.fT. NO.OF Np.OF CHECK � �� licenseNumber 37758� �;�,��a�_R -� - Size �.�3 SrOaiEs Fanniues 1 ONE . . - - '- - ...- -'.'- co�no�ro���' �DEN GROUp Dofe �IZg�85 ��RIVfION OF WORK � �yy � �'u�+T�ON_ Garage --'�'! . noo p s 70,102.00 :/ �J�Z�R � �l am exempt u�der Sec. -- � � AITER � � �• •2� 8.8P.C.for this reoson �yA�y � s 1 oafe: usE aF I •2,.9.1 9 i exisnr�eio�. �^� ❑ �_.. T APPLICAM �� 7EL • e C J`„1 Y V � � Signatu�e -�� FIHAt � J OWNER-BUILDER DECIARATION PR�NT NO. pK� ��/S�YS" G�.1 [-�S 1 1 herreby aHirm 1Fwf I pm exempt 4rom!he Gontractoi s Licanse � -. Lpw fo�ihe following reason(Sedian 7031.5,Business and ADDRESS NNAI/i��(7t�`�'l' :. elpfess�ons code�:.._. g� �G 6 l.4 A.. I,as owner of Ihe o ert y P y BuitDirvG `� t pr p y, or m em lo ees with appaE55 ff• • . • .� .. w, ages as their mle compenwtion,wilt do Ihe work and � the structure is not inrended or offered for sale(Section ����TM a(� n � '7pM,-'Business and Professions Code�. � MOwnIG � iet. � �� �:�" � I,as owner of the propeny,om exdasirely contmc�ing roNT�R� �' - • a(�' 1 ��p� 'wifh ticensed conimtton to Gonsiruct tke project(Seo- pDDRESS tion 7044,Bwiness.and Professions Code). , �, ��� 2..��, -- - CONSTRUCTION CENDING AGENCY R�gq� YAfro HWY TOTnt�`�fR M W�DTH I heraby affirm that Ihere is a construclion lendi�g ogency for pRpryi the peAormanca of Ihe work 4or which ehis permil is issued -� p.t:-- - . (Sec.3097.Civ.C.). SipE - - - lander'a Name Continental 111inoiS a.l. 4�2.Qa tDA4A Ref.M - Lender's ss � Z V �nnn� P�c.fee s-239.1.� Permir Fee � t cerlit ot t ov re d ehis.applicotion nnd smre thrn the _ .-y,n,,,K� 1Q.rj(j �p,yw piC k � .._ . _. ._ . _ _. __ . � abov miormo �c .1 ogrea to tomply with all Co nty Invastiyauon Fee g ord" ances t ws re�oting_to 6uilding constr .ion .,. ___._.___.,..__.____ , ,r,5,'�_ _ _.,_ u an here u iz r resentrnives of�his Counry ent r ��� -i'�'F°° �� "' tOvna Perm.M ' � o n th -me f ned propery for inspecti �r ° s. / � . _ __ _ _. �- �G $109.00 ID�7A $55.00 4 � � _... ffE REVFNSE FOQ EI[R�INATORY LANGUAGE � Signa af�pplimn�or AgerM - e- .. . . . � OO� I 7 °.. N C`Zy� S ' . �+ Vy•4•C ¢ � . Y. � X M w�, � Ijf C "� �- + ' , " 1 Oi 7�` �.L C v F':��'' V�� y ^� r0.u � a..�� . 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