HomeMy WebLinkAbout0573A 0574A (6) WORKERS'COMPENSATION DECUIRATION P13T1 D�3 �
I hereby nffirm that I have a�e,,,�;�o,e of�o�,a�,,o��F ��-qpp`�CATION FOR BUILDING PERMIT�
insure,or a cerrificote of Workers'Compen:atian Insurance, �eV. A
or o cerritiad copy rhereof(Sec.3800,tab.C.) COUPITY OF LOS ANGELES BUILDING AND SAFETY
����'945-104.(���y Aetna <
� Cartifiad copy is hereby furnishad. FOR APPLICAN�TO FILL�IN BUILDING
ADDRESS"
� Cenified copy is filed with rhe county bu�ld��g inspec- euaoiN�
tio�departmenf. ADDRE55 LOG4LITY Dla[[DIIC� $2.L'
NEAREST
ooC�/29(85 Applimn� THE ADIDIN GRO[JP an Di� Bar ziv 91765 CRO55 ST. 10 S GO
CFRTIFICAT€OF EXEMPTION FROM WOBKEFS' NO.OF 81DG5. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON�Oi hwa eOac PAGE PARCEL
(This section need nor be completed if the permi�ia for one 42584 +� � USE ZONE MAP �`��
hundred dollars(;loo)or less.) TRACT s�ocK LOT NO. NO.
TEI. SPECIAI r
I Certify thOt in fhe par{MmanCe o4 ihe wak for whi[h�his OWNER NO. — CONDITIpNS , . �
pefmit is iabued,18Fw11 nnt employ nny perspn i�any manner �1074 Park Zlieca I3rive DISTRICf GROUP TYPE FIttE PRIX#SSED BY �
w as ta became su6{act to the Wwkeri Compensotion Lows. �DRE D '� CONST�v,j/ Z V
c�n Covina z�v 91722
�-+�� g
Dn�e Applitanl STATISTICAL CLASSIFIG4TION AVT. CON00. F�
"�OTICE TO APPLICAN7: ff, aNer making Ihis Certiticate of . �CMtTEC[OR TEI.
/1 V
� �mption, you should betome subjecf to the Workera' ENGtNEER NO. — Qq55 hp,�+Q�DWELL.UNITS �+
,_ompensation provisions of the Ldwr Cpde,you must fonh- ppDRE55 SEWER nwP �
with comply with such provisions or �his permit�shall be �
deemed revoked. � � � E�� —
COMRACIOR $2E OFIIlE'r pp, 8K. i'G, VAUDATION
LICENSED CONTRACTORS DECtARATION � ���
I hereby affirm that�am lice�sed under provisions of Chapter 9 qoDRE55 � YAlUAT10H
(wmmencing with Seclion 7000)of Diviaion 3 of the Businesa and LIG �
Profeasiona Code,and my licenae ia in f�ll force and affecf. GTY c�,ass 5 (5.34�,OQ � �p 5 7.3 A
50:R. � NO OF NO.OF �CHECK
Licanse Num6ar 37�Ja0 Lic[lo-�• B SIZE � � STORIES � F IU 5 �- ONE
s �r �� �2�
Cor�aan«� �� � po�e 5/29/85 �ESCRIPTIONOfWORK S' Fam. Res. NEW �
noo r •22581
❑i am exempt under Set. C"�age Z AITER � FNAL/✓�/�, �� • �2 2�•�� �
6.8P.C.for Ihia reoson REPAIR � DATE
Date: EXS SiI1.G BLDG. pF/qp� ❑ Fuixt n 0 6 1 2�8 5
Si9nature APKICAM TEt. BY : ` �G 5 Z 4 A
OWNER-BUILDER DECIARATION ��NT NO.
I hereby affirm�hot I cm exempt from the Contractor's License � �• � � • � �
taw for the following reown{Section 7031.5,Buainess and ADDR[SS
v�ofe�io�5 codB>: ._. . I •3 9 Q G 6
� � BUILDING
� I,as owner ot�he properry, or my empbyees with � AppRESS - �---- ��-- �-
wages m thoir sol�compansation,will do the work and i�i TM • •�G U G 0�
rhe structura ia nor inrended or offered for sole(Section
7044,Business ond Professions Code). MOVING re�. _. - � , .. - 0 61 2—8 5
� I,as ewner of ihe properly,am exclusively controcting C NTRACTOR NO. �
with licensed contracton fo consirutl the projBct($ec- �R�
tion 7044,Business ond Professions Code).
REOUiRED TpTAt SETBACK FROM EX�ST.
CONSTRUCTION LENDING AGENLY �gq�K VARD HWY p�p ��N Wto7H
1 here6y affirm Ihot there is a construdion lendi�g agency for FRONT �
1he performance of the work for which this permie is issued p.�,
tSat.3097,Giv.G.). SI�E
- Cbntinental Illi.�i.s r`
Lender's Nume
$ 399 Park Ave., N.Y. 10�43 P.C.Fee S P��m��F�e
Lender's Address 'i
� I certif f h e r this a limtion ond state that the "�,
Y PP issuance Fee 10.50
� a6ove inf matio Is o ect.I agree to wmply with all Couny Inves�ipation Fee zQ �q
g ordinan s and a aws relafing fo 6uilding constr ion, Totol Fee d/�'V d
Yi and h eby a or' rep sentmives of this County t ent r
� �pon e o6 e- ti r perly fw inapoctio � s. . . .. .-. . . -�--
4 SEE REVFRSE FOR EXPLAMATOItY LAMGUAGE
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