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HomeMy Public PortalAbout4514 CLOVERLY AVE_Building__ WORKERS'COMPENSATION DECLARATION. l sure, a car that l have r certificate of floe Ins to Insurance, APPLICATION' .FOR BUILDING PERMIT Insore, or a certiflcbte df Workers'Compensation Insurance, • or d certified copy thereof (Sec. 380D, Lab.C:,) . Policy No. 1039547 . Company$taCe 'Compensation COUNTY OF LOS ANGELES,; BUILDING AND SAFETY Certif led copy Is hereby furnished. FOR APPLICANT TO FILL IN BUILDING . ADDRESS ® Cettlfled copy Is filed with the coun6yF Uil g I BUILDING tion Opallment. ADDRESS 4514 Cloverl Date .1/3/89— ;4pp11 t CITY Temple Cit zip LocurrY NO.OF B1 X-.& NEAREST CE3MFfCATE.OF EXF%PTION FROM WDRKERS' SIZE OF LOT 24 sqs Now ON ST. COMPENSATION'INSURANCE, CMIs.section need.not be'cam' leted if the permit Is for one TRACT BLOCK L NO. ASSEPd-dWSSOR PAGE P hundred dollars (SID4ypr lep . .- ' . USE. I cgrtlfy'tiat'ln the pdrfomr once of the work fol which this owr�i'Robert Hines No286- 221 permlt Is Issued, I shall not employ any person In any manner 502© Camellia COt O{� 2 ab as to become subjectYd-thb Workers C6rnperlegtlon Lows. ADDRESS �{ Dar. Applicant CITYTe le Cit ZIP91780 ARCHITECT OR Ta. after making t r. Certificate of DISTRICT RRE BY O. NOTICE TO APPLICANT: If, ng NO, Exemption, you tt4ould become subldd to the Workers ZONE j Compenlatlon provitions of the Lobor'Code, you must forth- ADDRESS with comply with such provJslors or this permit,shall be deemed.revoked. Te 'ATISTK'�41 CLA.SSi TION APT. CONDO. _ coNTRAcroR mite Roofing .223-4081 �L WCENSED CONTRACTORS DECLARATION. -CLAMd L�NDW9. UNITS 1 hereby affirm that I am Ikensed under provisions of Chapter 9 ADDRESS 821 baI 8 NO.1 (commencing with Section 7400)of Divbbn 3 of the Busmen and LIG a MAP Mofesslorts Code,and my Ikense is In full farce and effect. CIrY Y,- An ele-s Qus J✓39 Bk. PG. oto v�uwrN Sa Fr. No. Np.of cmc 1 ' Llfense Number 1'A7'690 Llc Clan V-149 SIZE "24 STOREI OHNE ACCT.i •`1-3,.89 Install 3 tab NEN .;' viuuAraly Conrrxtor D�scRlPitON of wORtc .4- 11000,00 7 - I ani exempt under Sec fiber lass shingles over ALS , 1 DIM B.&P.C. for this 7eason "'Alt R�AIR ; TOTAL 30 - 510 �- oar.: usE OF residence DEMoI E{ . 30-`0 IX Nd BLDG. SI nature APPUCANT TEL —- .0� g OWNER-BUILDER DECLARATION PR1NT tv0. DATI I hereby afflrm that I am exempt from the Contractor's License 1/ Law for the following reason (SeCNon•70�1.5, Business and ADDRESS Professlors Code): 09013-000�' 1/30/99. ElI, as owner of the property, or,my employees with ADDDRRESS 1 1�. ' wages as their sole compensation,will do the work and the structure 4.not Intended or offered for sole(Section L 7044, Business and Profesilorts Code}. MOVINQ TEL I, as owner of the property,am exclusively contracting �' with licarsed contractors to construct the project (Seo-. . rign 7044, Business and Professions Code). L SEMACK FROM tONST�RUCIIION LENDIt4G AGENCY YARD HWY PROP;4J TN I hereby affirm that there-Is a conatructiort kmding agency for FRONT the performance of the work for whlch.thls petmnit Is Issued - (Sec• 3997, Ov.C. SIDE P.L. Lenders Name - P.C. Fee S one it itFw 20.Op LDAAA Ref. / Lenders Add<bss I c;wr* that I h q" read this application and slate that the i,..Fee-10.50' LDAAA:RC f above Information is camel. I agree to comply wlth alL County Invewioanon Fee ordinances and State relating to building construction, Total_Fee 3O- 50 P. f and authorize Ivea of this County to enter b upon th ve-m orad Inapectlon $ fi R VMIII POR DpLANATORY WWJW of App4lom. or.Apent _ ,. 1 � APPLICATION FOR BUILDING—PER-1oAIT - DIVISION OF MLDING AND SAFETY fU(LDING ' t9wer ADDREM 4 DSparbnoif of CoDnf7 EugfnMr tgW CoMmf7 of Los Angeles LOCALITY xz;EK 30 WM.J.FOX,COUNTY ENGINEER NEAREST / CA GATT D.GRIF1rIH, SuP"fDF tun.Dlw• E'�L� "'� !/1� sk DtIYT N0. G fLYVtlt ' FOR A puc.ANT TO FIll IN \ TnEml BUILDING-SS O , ADDRESS ECIA - ! LOT NO. ■LOCI[ UZON SPNDITIOLN■ , TRACT 2 SISI/��/� /400 N0.OF SIL,DGS.. StZE OF LOT - - HOW ON LOT y 11" CK YARD 'MwY STREICf N"z- p US OF RLD FRONT ` rI i - ja TRACT tiW101--`t UNIT' f! INDUST121AL CITY TEL, ,. I 1 DWELL L UNIT d PUILIC BLDG. " ARCHITECT OR Ta. DUPLEX f UNIT 7 DN..ALT.. ETC. 'ENGINE NO. 8 APT. UNITS 8 ISCR. ra 4 COMML)tciAL +�1 CONTRA NO. J1RrJCJ<�..iaON BECORD . DE4CER5TION OF,WORK NEW ADD ALTER REPAIR DEMOLISH _ SQ. FT. NO. OF NO. OF SIZE STORI FAMILIA i SIGNATUR APPLI - PROVALS ADDRESS ` DAT[ LUSFMICTOS'S SIGNATURE FOUNDATION: LOCATION P.C. s FORMS. MATERIALS FQ FRAM[ FIRE STOPS. YALU TION >r ■RACING SOLTS FURNACC LOCATION. - 1 H R Y A EDGE THAT 1 HAVE READ THIS GAS VENT DUCTS AltLIGAnON AN TIL THAT THE ABOVB IS C'ORR[CT AND AGREE TO Y Y Vi"TH ALL COUNTY ORDINANCES LATH INT. AND STATE ULATING ■ULL.DINGUC- noH. LATH KILT. SIGNATU HOUSE NUM19 1E!COIR- FERiI RECT AND POSTED ADD FINAL kVM.J. CouNTY aNGINmM VALIDATION C.N. DIR .CHIMr E L.DO. INSPECTOR 1( 9 4 9 1OCT �D3 . 4 .0 0 �