Loading...
HomeMy WebLinkAbout1217 PORTO GRANDE (7) WORKERS'C044PENSATIO.'J DECLARATION � I herr.by o«�m tha�I have a certifica�e o<<0�5����o,��f APPLICATION FOR PERMIT i�s��e,or n cerlificale of Vlorkers'Compensafion Insurance, �tA3MC HEATING - VENTILATING - AIR CONDITIONING or�Q�j ��(�r.d copy hereof(Sr.c.3fl00 Lay,C.) �{" � ` �CE-AIA�2EV.10/91) ❑oF licy ,��. Company�;�� � . Ceri�l�ed co�y is hr,�r,by furn�s ed. COUNTY OF LOS ANGELES BUILDING AND SAF TY • /� �rd coPy is(ilr.d wiih ihe couniy bu�ld�nQQ��spec- fOR APPLICANT TO FILL IN 6UitDinlG lion deporlmen. ���� /�1(` hDDFE55� / / � �P71NT C4 TYPE ONLY) Da'e �� APPlicant ����C ( � IOCnLIiY ' NO. TYC?CF AC7�IA1�'CE CR ECU�P'"ENT FEE CERTIFICATE OF EXEfAPTION FR01,1 VlORKERS' n;EacEST �T" ,/,�`�/�� p COMPENSATION IhSURANCE CROSS 5T. /�' Tc�.��A y (This sacfion nood noT ba compl�bd 11}ha work Involved by /+nSCa:nCN U'.iT,BrU o�si+u r+u PPp:E15[D BV Ihe permil Is for one hundrad dollars(5100)or lest.) I terliiy thof in Ihe performonce of tFC work(or which Ihis h�R HA�DLItiG L'NIT,CF!.1 `� pnrmit is issued,I sholl not rmploy ony person in any monner � .�.P�� so os lo become subject�o Ihe 1Yorkers'Compensation Laws. BO'LER,6iU PGP40VA15 oare IYSP(CICP'S 5'GY4TU-F Da1e � Applicanl CO:'F:ESSOR,BTI,I_,��.ldo 3 g� O a ROUGH � NOTICE TO AFPIICANT: If, oi�cr mnk�ng ihis CerGiico'c of VFNTRATiCnl5V5iF'd FIN1L a/ E�emp�ion, you should becomc subjec� to thc lVorkcrs' �/ Compensclion provisions ai�hr.Lnbor Code,you musl forth- EVnvOqATIV'COCLfR VALIDATION �/ witn compiy with sucn provisions er this permit sholl be . �eemedrevoked. FU44ACE: FAV_Go�VITV LICENSED CONTRACTORS DECLARATION iLOOR BtU 00 p _ I hcreby offfrm iFol I am I�c�nsed�ndrr provisions of Choprr,r 9 ' SUS%ENGED UNiT_ HFAT(R: W��� �(commencing wi�h Seclion 7000)o(Division�el ihe Busine.ss ' � ond Rofessiens Code,ond my I�cen<e�s in f�il fo�ce and eifect. —�� / � �" �ca��� C d2Q — a License N�m6rr Lit.Class_ , V K com�a�fo,i� oar�3 i�D—p :�2 3 1,8 A � u ❑ I am e•ernpl�nd^r cc. �y Plcn check fee N. . . . .�j a 6.RP.C.for this renson z ��ie: PERMIi ISSUING FEE S �� I • 1 5�,7,ri Signarure TOTAL FEE � � � y� 7�� OWhER-�UitDE4 DECLA4ATION PIAN CHfCK AFPIICANT I here6y a!firm Ihal I am r.zempi Irom the Controcto.'s Lice.nsc , ��.L� —�4 Low for the(ollowing reason(Sec!�on 7031.5,��sin^ss ond NnA'E Professions Codr.): ❑ I, ns ownrr of ihn n�o���+y, o� my r,m�loyres wi�h ACD�E55 woges os Ih�ir zole compensation,will do the work and �ITY � TEL.NO. ' th�slrutture is nol in!ended nr ailered(cr sale�Sec�ion 7044,Business ond Prefr.ssions Code). � O'.5'NER �y&fl pUILDERB . I,as owncr ol 1hc properly,om c:dusively tontrncting . wi�h I�censed contrnctors�o mnStruU the project'($=o- ^'�'�� lion 70=4,Dusin^ss and Prc!=ssio�s Code). ADCRESS �ONICA.�A CONSTRUCTION LEkDING AGENCY aTv TCL,n10. ' I hereby a(firm�hai ihere iz a conslruciion lendin�aqency(ar �he prrformnncn.of the work for which Ihis pr.rmil is issued �CNTaACt�FE1'VAT HEATIN , �Sec.3097,C�v.C.J. 86C8 �ERVtC5f1 . ' ncoc�ss E• 1MPERIAL HIGHWAY Lender's Name SANT� r�p�M� � CITY TFL.NO. . lendcr's Addrrss STnIE UC. I c^d�fy�hol I hav�read th�s appl�mtion and s+oic�ha�ih? ❑CENSENO ��� C1n55 C� r above in(ormaiion is correcl.I agree lo comply wiih all County ardinances ond Stale lows rrintin9 lo buildinq conslruclion, and hcreby auihorizc representatives of this County io en�cr � upon thc abc�e• entionrd property fer inspet��on pu�pos . SEE REVERSE FOR EXPLANATDRY LANGUAGE n�,���_d-,�-- .3-ao-� s������.e or n��i�co�•o•n,c�i o�,�. N ,, .' - ; �%� . e . '/. ;; � , f� ' i _ ' �, , . _ ` -• , f , � " . �. � � f, . . . � 5'. ' / •/ . m . ' 'i • ' a �'� �� Q . " . N �,' •t' Q � � N . i [/'� r � �� f'• ' f's � . � �i�, �J t �J ` . � l '�/ . :i� ` � ' 't „ � ' ! t ' f � /, N 'O . i J " (� . `, � 'I', J � ,�• . Q � ` 1 N .'. . � + _ ` ' `/ :/ , " I r •'r� � ,�, , ' � C�r � � v, C O �, �,f1�'c t� , � / n `�O �i n > ?n � C' n � U � , � t7� �w � � � � n r N C � � r� I' C� ' f f ° �� '= n ��:` n� r. y�' ' r n ° � L �..;� '�„ , 0 3 ? p � ,�n �r � p r, a f � � O f T C �c.� r ��( I�'^ C1 C Ci C��.T n 7 n � ~ Z � °� r�� •' o o a cr � o �_ �v,o" n v c� N �v ,<, -• v p � ' fn �n � �,:�': I C -. � t =-�', i] y c Q n n n p � r �;�, �% p _/�' �(,' . P p � v ; ..�,.a��Q • ir° a.� cN N o `?`<<u� o n _; - �; fF ` � S� � �� �i9,�" .�'. " O c- � �' = r p `^ :�. r r�G O'v7 � �� U N � � C �O a7 � � n��,i!�u �?�T� C � 7 � �v n N� M �� p � V C � r Q r x n ry w ��W:. , _. �t _. ti N :� o � x �' , n �, ;_ � �' 7 (1 � p c �O 3 � �' � �j � � _ t]_n n � -..p CL�, n � �i1 � I.1r1� �� � � 'N 0 N (� .r�' 'J . N ! <.Z: U �n '. C:� �7 �, Cs ��l C 7 -. � t C. /`. • o -.� -� - � � � � ° 'O; �'�c �. a �.', o '�=. �'„ �i„�, � ^'.. Cc:= o � . N _. 7 � n < u. .!'��r o �� � : �� � G r 7'�c: o'N^ v-OF r � f ., �s o "'n. "' 3 � 0?ii� �i� ' -?',�. n ` �; G- n c � N � ^'�� � � ='�.c :`,o � c:. w o c .,i.: ^''' =�I� '' n ""��'� �, � c '�" � N a "� � So = ' ��-c'z � � ° 3n ' .:.r' '' o; �, � ^ � ° • A C` U' r?T � i; � r C� �C t1 <= �� � �� t�. ^.� .tl:7.c _.7 � ' -. �4 w n O f � � ' ' � C. ...S�� j {i j� _: � f���.C -N J V��5. .. � � .�'�' n f.Z7 CI O•2'+ � �•,c ti �.� V 7 i � U :� n^�; C n �i 1'l f:. ' �f 1 -' O �.: �CJ�,'^ C� 'O � t7 � � t n ('1:1 � "^tc C: Q ^ 3 0 r. _: < ! —. (1?~ L . �•'C; � ,�„ �r C' ""�' ; O v'C �ri'.�: C, �Ci � t� f rf u't0 ' C.�7('7 C .! "�f,:�'�I � c'n ��-� n S :1 � ' -' � y� '' j � U h ,[! r.'.K �.!.�. n�= n _ = a o n •_ -'- ,�, —��: � r.�.��= w cl N..`� ��:i•, � , � ".= � ° °. ia � ° o r i ,� v�ao � ° °'= �. � �.�^! U j o r� n o u v C' v'� [-n t't n �• O ��o L " ° C =j�✓� �- '� � v -- s G c- n o ?r �'t'r ° c ;�`' ' - �_��. .� c o � ...� �-.t�c v� � _ v o � � �� � c o v ' c � _� � �-•� S; C:. ' -�'+ C^1 (�,t, �i- � , j_,'�j '� � " p 4 .�� , n � ' _� n N j �. C? h Cl.�.D U 3„` � '._�� � � r"r o a� � -��-^�- ; - . � �K ( i�-- -__I� _�-i . ���i -�- I� �• --� i��