HomeMy WebLinkAbout0575A 0576A (4) � WORKERS'COMPENSATION DECtARA710N rCot 6 a �
I hereby affirm that 1 huve o certificate of tonseni to,��fP� �3 , APPLiCATiON F4R BUILDING PERMIT
insure,or a certifim�e of Workers'Compensation Insurance,�jeV. C
or a certifiad copy thereof(Sec.3800,Lab.C.J
F$(��TS-945-1(Id (aaa�pa„y
A,et�a COUNTY Of LOS ANGELES eU1lDING AND SAFETY
� Certified copy is here6y furnished. FOR APPLICANT TQ FILL IN BUILDING
ADDRE55 •
� Certified copy is filed wi�h ihe county building inspec- 6VilDiNG
tion department. AD�RESS 24377 Vista Buena Dtive ����Y Diamoi�d B3r
Date 5/29/85 NEARE57
Applicanf � I�IDFN (�OLTP arr ziP cRosssT. io Go r'
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BIDGS. n55E550R
COMPENSAiION INSURANCE SIZE OF LOT NOW ON LOT MHP BOOK VAGE PARCEI
(This section nead not be completed if the permit is for one 115E 20NE AM /
hundred dollon(5100)or less.� TRAR BLOCK LOT NO. OQ � N0. • ��
TEL �—� SPECIAL
I certify thot in ihe performance of fha work for which this OWNERT� ��IN �P r,o.967-9541 CONDITIONS 6}.
permit is issued,I shall not employ any person in any manner DIS7RICT GROUP TYPE fIRE PROCFSSE�BY C1
so as fo become subject to the Workers'Compenaotion Laws. ADDRE ] P3r']{ jJl _ /O � CONST._y.,r ZpNE V
TIA/ �
Dale A lican� �TY ��� ZIP 9�-722 d«+'••
� ARCHITECTO{� TE� STATISTICAI C1A551FICATON APT pp O
-"OTICE TO A�LICANT: If, oiter making this Cartificafe of ENGINEER S�1 & AS.SOC, wo.445-4073 pq�5 pp,��DwELI.UNITS� �
3mption, you ahould 6emme wbjecl to fhe-Workers'
��-�ompensation provisions of the labor Code,you must forth- p��F� SEWER MAP +r
with comply with s�ch provisions ar this permit shall be iEi. �
deemed revoked. —
IICENSED CONTRACfORS DECUIRATION ��RACfORS22 QAII1P•1 pp. BK. PG, VALIDATION
i hereby affirm thar f am licensed under provisions of Chopter 9 qppRE55 N�7�.rJ8� VALUAFION
(commerxing with Section 7000)of Divisfon 3 of the Busiriess and �K
ProEessions Code,and my 4iceme is in(vIM force ond effecf. CITY B
so.�r. n,o.oF Na.aF ��� CHEIX S 65 340.00 � �p 5 7,5 A
I.itense Num6er 3�1��i80 Lic.Clasz R SIZE Q STORIES rnmiues 1 ONE
s #;.. . .21
Contractor.R'G-1R ANI»F'A7 f,TNYtp pp�g�$y DESCRIPr10N OF WORK S . Fdill. �S, NEW �
N " ' ADD � I •2ZS.B�
�I am axempt under Sec. — ��7^ qtTER � FINAL
B.BP.C.for tbis reoson � DATE /�" 3/�S • e�G�.�•� c=i
REPAIR
oare: use oF F�r�u►t� __/,.( G 6 1 2—8•5
EXISTING BLIX'a. ��OL ❑ gY ����� U
$iflfWiVfe NPPLICANT TEL. �0 b?.6 A
OWNER-BUILDER DECLARAitON PRINT NO.
�hereby affirm that I om exempt from the Controctor's License � y. . . . � �
law for the follawing reason(Section 7031.5,B�siness and ADDRE55
Rofeuions Code): 1 •3 9 Q C 0
BIIILDING
I, as owner of the property, or my employeea with qpp� • •3�U}J U
. wages as their sola compensotion,will dn�hs work and
the atructu�e is not iNended or offerad for sale�SoUion � �TM . `�
S
7044,Business and Professions Code). MOVING TEt. Q 6,� C��j�
� I,as owner of the property,am exclusively contracting C NTRACTOR NO.
wilh licensed conrcaclors lo construcl the project(Sec- A�R� � �
tion 7044,Business ond Profesaions Code). ,
REQUIRED TOTAL SETeACK F2pM EXIST.
CONSTRUCTION IENDING AGENCY �T gq�K YARD Hwr p�P ��N wi�n� ,
I h9reby affirm that ihere i5 a tonsir�ction lending agency for FRONT
flte performonce of fhe work for whith fhis permit is issued p,�,
�Sec.3097,Civ.C.). SI�E
B L.
Lender's Name C.Qi1t1HP11�1 T71 i n i G
� P.C.Fee 5 Permit Fee 379.5�
Lander'�Address []3 �
� I certify thal ov r ld this opplitofion and stale thnt the Isnuance Fee '�
� above info atio rr c�.1 agree lo tomply with all County Invesiipotion Fea g� '�.
� ordinanc an 1 1 s elating to building consfru n, ioral Fee "7�-d�
YS ond her a ri ep xnwtives of thia Counry t nrer
� upon th a m tio d proparty fw inapecfl p pose. �
SEE ItEVfRSE FOY E%HAIiATORY UN6UA6fi
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