HomeMy WebLinkAbout0574A 6289A 6290A (4) i� .... ._.... . .... . ..... ..
N+ORKERS'COMPENSAflONDECLARATION . � . - � , � .
1 hereby 5�,$irm rhar I-have a�e.,,,;�a,e af�o�5e�,,o��f � ��� qpp��CAT14N FOR BUIL�DING PERMIT ��
insu�ia,or a certificote of Wo�kers'Compenwtion Insurance,
o�Sa ce��Jrified mpy 9hereof(Sec.3800,tob c� COUNTY OF LOS ANGELES BUILOING AND SAFETY
Pulic�IGp�6 s� Campony � �� -
� -Cecti4ied copy ia hereby furnished. FOR APPUCANT TO FILL IN BUILDING �
nooaEss ��� �
� Certifiad copy is filed wiih ihe couMy building inspec- BUIIDING
-�ion�deporfineM: ' ' qppRE55 LZ�Ij��E LJ.VN �b .
Date f—�p�plicant�� C�Tv ,Q//�aCdA/O �/}�1Z ZiP /��] .r
LOCNLI7Y
CERTIF4CATE OF EXEMPiION FROM WORKERS' - --� -- NO.OF eioGS. -� � n�FqRegT . . .. _ .
. . � SRE OF tOT NOW ON LOT '�Q '.�i�� �`
� WMPENSATION FNSURANCE ' /� �A CROSSST. .. _ i
�This aectio�.naed nW'be compbted if the permit i6 for one TRACf 3OO-/J BIOCK lOT NO. �T ��
hundred dallors(5100)or less) . - ryip,p 8pq�• �� � pq�� ���
1 certify tho�in tha performance of the worfc for which this
.' OWNER S/�/e'M 7�IDRlK -r�io���� ��.f3. u zor� r o I O S
permil�s iuued,1 sholl not employ any person in any manner A���Z`3 l�n �Y7I�/(r ( ���q� O
so ps fo become aubjecl to Ihe Work@n'CompCnsalion•tows. � ��% "��""'""' ' " a CON�I7IpN5
. . cRr bl�Fnt n RAr2 c;<{ zir /7b..l�. u
Date �-`�. �� �Applicant - �� � OC
_.___ . _
NOTICE-TO APPLIG4M� If, ufle�moking-ihia Certiffcate of A�����"T OR iE�,d'id O
Exem tion, � ENGINEER R OCGr y/jA/( p�p 2 DG..y"�� ,DISTRICT . _�RqVP. TYPE FIRE PitO�55Ep gy �
p you shouW become �ub'ea to the Worke�a' CONSi.^��� 2oNe W
COmpensotion proviaipna O�t}1e lobor Cmle,you must forfh- qDDRESS ��/T/��.Q[-- .R1/L ��CH/! �/6y6y1Y� �(; V IU � p,
�uith comP�Y with such provisions or lhia permi�shail be y�
deemed revoked. . � ��� ��El? �6y^t'3I yti �TqT15TICA1 Cll�SSIFICAIION .� ppi, �pNpp,.-,.., .Z
CONTRAC�OR �t�/b/L/< Cdt[CT7r. No � i -�2
LICENSED CONTRACTORS DECLARATtON . ��C. MSS NO.�OWEL�.uNi7S �
I hereby affirm that!am licensed under pravisioru of Chapter 9 q0oRE55 ZT '4/1/J/D E`{1/1�IQ,cI� p�p,
(wmmeuing with Sedion 7000)of Division 3 of the Business and SFWER hWP ' . - . -
Rofessions Code,and my license is in�full force and effecc CitY���4+/O �3/f!t ��f17G�CL455 ���-� - - .---.-------- � VAtIpAT10N
., � � f� SO.FT.A NO.OF NO.OF CHEIX � BK. GG. �
i Licensa Number��rr�� Lic:Ciass�'?^���� SRE� l�� STORIES � �FAMILIES � ONE
VALUATION
com.ac�o�f�tivauc [%o-R+ST��,•pare ...� �1_�.� DESCRIPTION OF WIXtK __ �W ❑ s" � r��{}- � - e 0�7,4 A
FS
noo
1 am exempf under Sac � � �l7V.�o%� !�j►(/t dW4Y/A[6 �iN AL1ER � . � .. v
B.&P.C.fw this reospn �:e.14n 7 jZ /j!,{([, �28 y+ ��.Q = 2 �• . • •2 3
.. Dare: Exssiirvc��. oerna `�'��°j �9� I •�6 G.6 3
" Sianafure . . . • . APPIICAN! . _. . .7EL. . . __---- FiNAL [ Q . a�,> 'L,Q�i.:.x
OWNER-BUILDERDEGARATION ��NT $�v� ���D/7// NO. pATF J���U� �
!lwrduy o#irm.thal 1 am exempt from Ih�Conkoctor's license �- h
Law for ihe following reason(Set�ion 7031.5, Business ond A��u p�Nq� � . O a�u-t�7
�Rofessions Coda): '. _ - - . . .- . . .
❑ , . . ...,_....�...__ __... ._. .
I, os owner of ihe ro r ���� 8r" �_ ��� . -
�626.'vH
p pe ty, or my employees with qppREu .
woges as their solc wmpensaFion,will do fhe work and - � H a • • e i�
the alructure is not in�ended or offerad for wle(Section ��Cn�rtY - ,
� 7041.$usin9u ond Professions Code). � MOVING � 7EL- � • .� %J:�S
� I,as owner of the propeny,am exclusively contracting CONTRnC70R NO. - -
'with li[en3Cd COhfM[fofs tO[onSKUC1 1Fie projB[f(Se[- qDDRE55 • _ � ��I�;"`S
tion 7044,8usiness and Prafessions Code). ��
REIX11RE0
CONSTRUCiION LEND�NG AGENCY- - - �gq� vARD HWY ��T�OP LINE WIDTH - � � � v �=� `�S
I hereby affirm fhaf ihere is o construc�io�lending ogency for FRONT J
ihe performance of the work for which tbis permii is issued p.L - - - . ��C q G A
(Sec.3097,Civ.C.�. SIDE
`� P.L ' rie •e • ��
Lender's Name ' "--"� �
� �` . .. LDMA Ref.A � �.2�a,��
= �Lender's Addreu � -- -.. -_.. ... � P.0 Fse S � PermN tae. ..� �.�.' . _ .
� L certify Ihat.l_have reod this oPPlicutien and atate that�he f � !Q t p s y9,�o,Ke� 1�`S� � �pMq PK q��� , , `'��».�'(;c$,�
a above information is coRed.I agree to tomply with all County Invesiigaeion fee e
� ordinances and 51ate laws relaling to building consiruction, ��a il;,'� "cg�
� and�he�eby authorize reprasenmtives of this County�o enter -- �- � " - � '�- T`"�F°° ���� IDMA Perm.N '
5 �n the a--5 i�n�ioned property�inspection purposes. ��M _ � A^_ ----- ---_ �� _ '
� ' �� - i�� �) - -
SE[NEVERfE iOR EXMANATORY LANGUAGE
Signrnuro of Applkont or Aqent po�e. .._.. _. _ � �� �
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