HomeMy WebLinkAbout0957A � �7 �. -�, �.
j WORKERS'CQMPFNSATtON OEClARATION . , �. . .. _ , ,� - �
I�hereby a((irm fhol I have a certificate of consent to 5e�f - APPNCATIQN Ft?!� BUILDING FERMIT
insute,or a certifico�e of Workers'Campenstioa Insutance,or
a certified��copy'Jihereol(Sec.3800,tab.C.) ' CQUNTY QF!4S ANGELES� � SUiZDING AMp SAFE1'Y �',�J�'_ �
P��titytJU,r��y,����{�Company Q�I(3 �••CS'. ... q '
PY Y F4R APPLlCANT TO Ff1.0 IN nooaEss G LLft C C it�,/J
Cerlified�o �s hereb furnished. f
� Cenii�ed copy is(�led wirh ihe county build�ng inspoo eui�piN�� � �IA�1
iion depnrtmeot: ADbRF55 tOChtiTY�- jY Jr�^` -
oo� — 27 8a APp�,�o�, �tC7�� arv �AC-�1�a� �' z�P cRoss sr. ll��L/�/((9" ,p
� CERTtPiCATE OP ExEMMiON PROM WORKERS' . . � NO.OF BtDGS. n55e550z � � �
COMPENSATION WSURANCE ' S12E OF Ld7 . ' _ NbW ON LOT MAP e00K PAGE PARCEI
(th ection nasd not 6e completed i(the per is for one ,Lyh u5e zoraE rhnP J�
' bundre ollars(SIOQ)or less.) , iRnCt BLOCK L NO. NO, �� �
d �yJ j!t� SE4 �y SFECtRt - � y '
OWNER /!�+ y'/( /vY d�P NO % � CONDITIONS �
I certify�hat i e performance e wark for whfch this � O �
�} QI$TR1�7 G UP lYPF F1RE PRp�Q$SED BY
permit is isaued,I II not em y any penan 4n ony manner /t d � /� CONSi ZO V {
SO oS to bBtome su'D�, i P ADDRESS j!d 1/ � {f C�
.e Workers'Com ensotion taws. �[, �/�J t!/ r J ���7 ,/ � � � CC •
ti7Y �� P�Lt tC� ZIP �C Y' �t ��, �� Y a `
• F„
Oote �Appii[o . .. � - TE� S7ATISiICALCLA551FIGilON � APT. ONDp. V .
ARCHITECT OR.
NOTICE TO ICANT: If, after ing'fhis Cerrificate of "' � � � -t++
Exemptio yau shoutd become s�b� to the Workers' ENGINfER `�".��'� � t�Q. Cl.45S N4. OwEtt.UN�TS_ N
Com salion provisions o(Ihe labor Code, must forfh- • qDDRE55 � - � �� 5£WER M.�.P �
w' compty with such provisians ar ihis Rerm sholl be �� "
' eemed revoked. . ' . �- CONTRACTOR .d� pjp, -Qq BK. VALIDATION ,
� � UCENSfD CONTRACTORS DECtARA7lQN� ,/')���� ���,
i heroby o$irm that I om licansed under provisionx of Cbopter 9 ADORESS�ZC? 1„JJL�.I NO �� VAWATIQN � �� ' �
(commencing with Sedion 700Q)of Divislon 3 of the Buseness ond ,? ttC, .p� 2� ��„ i
;Profes5�ans Code,nnd my ticensa is in(uIt force and efieri. CITY /'�"""� CLA55 a s V" Cl �
p SQ.F / �J Np,OF / NO.OF CHECK " ' � !
tttense M1TUmber�I � lic.CI05S� 57ZE cj�L' STG7RifS 1 FAMittES t7NE �
7 �Z s +
Confractor Date��'�`r �SCR�PT�ONOF WQRK NEW. Q . ' . i
m exe rom t li nsing requirem om a f� �� ADD' � . . _ �
Iicen c iie�t ar a r qistered s�onal engineer . . . . . . . aliER Q FINAt ,yF�,, � . . ,
acting in m fossi mpaci�f�ettion 7051, � �AT� .� � V�..... � '
0usiness ond Pr•; ' e. tieaAl4 .
� _ usE oF ,/� !�`. - oEMO� FINAL �
Ex15TING BLDG.R/F.K�K � 8Y ,�
(.it g.Na. Oote �"^�-.. AFPlI{AMT TEI. . � �
'- � � OWNER-BUILpER L7ECLARATION ' fPRiNt1 NO. ' - /J� /�f � ,
ereby otfirm ihot i arn ezempt from the Contmctor's ticens� l' ��
_ to for rhe foilowing reasvn�Seclion 7031.5, B�siness and ADDkE55� ' !"'//�/,p� ,
Proie 'ons Code)_ � � � - �gt�K� �! c� . �
❑ - BUitD�NG .. ... . . _ . _ ._. . , - .
� I, owner.oF fhe praperty, pr my emplo es wjth nopBESs
wage s lheir sple cempensotton,wiii do e worjc and {p�Atiri
the siru� re is not imended or offere r soie(Sec�ian � ' -� � ' , � � �
7044,Buzin s and ProfesSions Co ' MOVING tEe. -s,n c*-r r
� I,as owner of propeny,o exdusively mniraciing CONTRAGTOR � �a� . , c n e o 1 '
w�th licensed ca�� ctors t cons�rucl Ihe projec�(Sea AQpR�� � . ' ,
- tioe 76dd,Business o rofessions Code}. j � . '
RE4IUIRED TO1AL SET6ACK FRpM EXIST. p(7�. '
CONSTRUC N{ DWG AGENCY SET BACK YARO HWY PROP.uNE WIDiH ' . �� 'f °� � � -�
-I fieraby afiirm that th e is a cons ctian IBnding agency for ppqryi " ' f „� ��„t. ;,_ �
Ihe performonce o e work for wh�, �his perrnir is inued v.L ' , � -� • - � ,
�(Sec.3Q47,Civ. .). . . . _ . . . StDE. . . .. . e . . �
P.4. . . ; l.. .;��w_-k_�'t
(ender's me ` � . . ._. �. , . .
/�'^ f p O�
$ � � P.C.Fee S/✓�S Permif Fea / ,J , "-�� �
L ar's Address �J
y I cerlify thpt I hove repd this applimtion and sta�e thaf Ih8 Issuance Fen �� �{� p� .
Q _ above,informmion is correct i agree to Comply wilh afl Counfy. �,,,.Esr�gortan rse ���- � - - � �f'j V/j /y� � •�
� � ord�nonces ond Siote Ia s relaNng io buiiding cpnsirvcrion, Toiol Fee r //� 1 /��
and hereby ou�horize preaent ves oi fhis Coun�y to emer f � ,
= vpon ihe above- e � ned pro .rty for inspect7an pv'r'')pos�efs. . "
� 1�—f—i-U f! ' SEE REVERSE FOR EXPtANATORY tANGUAGf / . .
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