Loading...
HomeMy WebLinkAbout1217 PORTO GRANDE (15) 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�,�. - �i i ' r%I . �� �. ' �� , . t ri . I� , t . . .T' . . � +� ' � ' J � . - � r. . � , • . , -j, - . 'S ..; ,:r . , . . .. /. Z ,� � ,` '�. � , � • ,,�/ '. � i N� � ' � N � . r . C;�. J� � ,� . ' � � �, �;.. �� , . ,�. � �j ' �.� � . . 'i . i � '! / , �.. �O ' � n • � , � � �, p . ; �r w . "r'• + � .. '� ` • ' � � .,' . . �'i i �! r ,� : � • 7! . ` � � . . •i ,t . ~ ,/' . o � p c,o .n y ,� U �o�, � � c � w v ` f f w R p O -�+'N��? N'4 W v� �� I' O `=3� - ° � �"7�'cc ° C' L . � £ f °'�' �' � �`n o�.o �, '' c v o.� ~ Z • ;� _ o �? o o N^ v \\�n c� �- c��, .-r z� � � v a% �' tn •`✓ 0 2 �c � ,c- ::...,4 a< n �n v. a ,��c � j � p' . � � cf � O (� � �. fs n 0�?��,; �^ O �•.G � �n f. o� r� • C o O a.T c. O y,c o n^. 7 � —` � r, . . ""C .T y�f: � C f5 Q.� � O w<•<�: Q O n � C O N N ^ '�' � O 3 U r ��' ' C �, N n Q . p . -- 6 • ? v�� .. � Q C�r C ('� II' � U t:1� �L+.C,� O = ''N N `t � ^l'[� n O O N G � V 4j p �a � O'O G t9 } L - O [L�O "n C > > ;f O�y� ?�. r-� � fi i `r O � �� Q S� 7 O �y 7.J��C � .,. '� .{. tY J '�.. �n n �J �« O Gi'Y . .'�., C 1 x fl � � U � " � .^.. a � � '� -o f. N C �.ti U '" .'.° n �' v � � � :� � °c �' ° U { G •C1 l: r N (n S N Q ",' � K :. ,� 7 � N O �. f �. , : (t\ 7 � � N � j �j O �`G Ln p T 1 O p'CJ „;, '?c:q .��..' ..T'�� C� �� � •� ' '�, n n (; ' 3 C.. . � O�C t� .l � � t� r �` � J '..�T. OG y� �A-O= � � �C �, �+` D �� tL"' p Ci ,,,Z,� �,3.�3 f� �„C C" �'�'. '�^' ', � � n o q p n� ^ � Q,i'�_t� '��'�i fi n n O C'' ..:.C: '� U.".v � ^_.6 C r` .�, n c < � '� % '.'. � � n a � o .;��-- ° u c o f-:.� n�;'Q °.:.�' ° 3. � � `,�,�,� n G ���� �', ,,O ' c v� .-?? c o„�o c ` t '_='`� 'o � `'; � a ' `> �a��t Sc ° �� =. n;,..'L �'' • O n � n ��� a °•n -a 1D n n 3 n � n a-% i5�r ii i °� o �, � " .:�: J � . ' p C�-Gf,.`� U � 'p Z} Q C- - r 4 N t[1 ;'' C«�� ./ .. ` -, f � v n� � + � O �p y(���� „`�: � �7 j � v C� C1 ^.�' V��,, . { �� N "^F'i "p ° O'?; � � � 4 ^ ti c c�: -�'' �- 7 w �, `^ i1f_ ..c �C�� , � u, O Q ;,y U �.c: � N� �o cf� �.. Q ✓, j in.^ � g � C' � y ° � 's m ? c_°i� � c q� i+ �°` =�° � 3 ���.. r ... _ � �, ci�;,�i,_c ci-n n ic �-o p ° t i�, j� ''�° % :.':�u� � T�'.c.� �, n � �'v o '"-• '". ' /� ^ - n i: -o ,. c? q =� "' ,,.� Gi O f j; G ..-7 7 �' C -�; �! C„ �"' // ; --, �;-�, �' �s u - �,� `: � � " O 7 p n n;�'o o ' ��/" � � ': o a n " /// , M � � � -• ^� �. � � // � �/I ////� ' // / / '/� / J'