HomeMy WebLinkAbout0613A 0614A (6) _. .__. �.
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� '' 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
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