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HomeMy WebLinkAbout1078A 1907A � WORKERS'CO�dPEN DECIARATION����LN 1`��"-`C— ,` ' ��suraborflfcertifh�' ' rkes''Com�pensatonlnsuronca APPLICATION FOR.�'��1�IL-�ING PERMIT � or a ce�rifi d r of(Set.3800,Lob.C ._ COUNTY OF LOS ANGELES �'y,,,,r'" BUIID{NG�AND SAFETY PolicyN . Company — .� n� � •. �_ Cernfied copy�s hereby furnished. — � � FOR APPLICANT TO Flll N euuowc }I � ADDRE55 � �l-1Cei�ified copy ie filed wifh iha coonry uilding ins ac- � BURDwG tian departmenf. ADDRESS Gt.t�.{ . Q 1 /��'� Dale� Applicant �,� ' �"_7L{� CITY ZIF tOCAIITY , `t w.cv� � CERT�EXEMPTIO FROM WORKERS' V NO.OF BlDGS. NEAREST COMPENSATION WSURANCE � � SIZE OF lOT NOw ON t07 GRo55 ST. (Th Saction nead noi be�completed if the permil ie fvr one TRAn (�,d�� �aK LOT NO. �ESSOR hun r dallars(5100)or less.) MAP 800K � PAGE PARCEI TEL. OWNER USE ZONE ' MAP ��a I cartify rhat Iha performonce of fhe work for whith this J N�� NO. �� � permit is Issued, oll not employ any person in any manner 1 SPECtAI � so aa ta become svb ��o ihe Workers'Campensm�on Lows. ADoaE55 CONDITIONS 0 Date Applic � aiv � r" ziv � V � NOTICE TO APPLICANT: If, after king�lhis Cerlifica�e oi ��' TE�• '(Q DISTRICT GROUP TY7E FiRE PROCE$SEDBY O Examptian, you should become su 'oc1 to the Workers' ENGINEER NO CO ZONE F- Compensotion provision�of tha lobor e,you mus�forth- poDCESS e{� � N W wilh comply with suth provisions or this ermir shall be . • TEL. Q STAiISTICAI CVv551FICATION AVT. CON�O, � daemad revokad. coNtanct ^ I z , LICENSEDCONTRACTORSDECLARATION n• ' ��. U MSSNO.�DWEL[.UNITS , 1 hereby affirm iho�I am ticansed under provisions of Chapter 9 qDDRE 7, � �r NO. b '� (commencing wirb Section 7000)o(Division 7 of ihe Businesa and pn 0 ��� SEWER MAP I Prafessions Coda,and my Iicense is in full force and aHecA Ott • J LD C1a55 � BK, aG. � VAUDATION 2 �1 50.FT��� NO.OF NO.OF CHECK Licensa Number v Lic.CIas1 SIZE STORlES FAMILIES ONE . Controcfo y 1 a�e � OESGRiPTiON OF WORK N� � �AIUAT�ON , � S ADD S�`T-�a�—'• , em 1 under Sac. '` AITER � � . 8.8P.C.for thi reoson •• � � • REPaiR ❑ s � �� �7•a n Dot : USE' f � . 1 . _ EXISTING BLDG. ❑ ' ' Si9nOfufe APP�IGIN7 . T�, ] rf/I #� • • •`Z 3 OW ER-BUIIDER CECIAR ION FRiNt N�• � DA E` ,�� / 1. /,J� ( . � (�[�$Q �1 areby affirm tha I om axempf from th Contractor's l(cense � ' A ��1 9 �: La for the following reoson(SeUion 7051.5,Business and ADoae55 Ll!!il FINAL � Proi sions Cada): . ey /� • • � �1�J.Jr Q� OBIJIlOMG �- - ' I, s owner of tha prope�iy, or my employaes wiih aDDRE55 C e V 0 8.2 4—8 8 wo s os rbair sole rompensotion,will do the work and ' � , - � the st cWra is nol inlended or alfared for sole(Sect(on ����TY . 70a4,B Inese and Pro(essions CodaJ. G� Tet. � � I,os owne f tha prope�fy,om exclusively conlrncting CONTRA NO. with Iicense comracrors fo mnstrvct the prolect(Seo- AooR¢55 � ' tion 7044,Busi ess and Professions Code). ' . REqUINED IOiAL SEiBACK I CONSTRU ON LENDING AGENCY SET anCK YARD HWv PkOP.IINE WIDT11 1 he�eby afiirm that�here i consrruc�ion lendinq ogency for faONt . - ?� 9 p']a the pa�formonce oi ihe wor or whith ihis parmil is issued P,l. (Se[.3097,Civ.C.). SIDE . . �• • � • P.l. °� lender's Noma 1 • � �Q 5 n ('� `'.�O�a. tDMA Rei.X e Lender's Addrcss v.[.F�o f� ,.. V Vermii Fee • � a Q 5(}� � I certify that 1 have reod this opplimtion an t thot Iha _ ismance Fee �,_ I�MA ViC M � 0 9 2 6—8 g obova informolion is torretl.I agree to comply with all County Investipolion Fee A O , � � ardinences and Sta+e laws rebting ro building consfrucrian, . Totol Fee �f� LDMA Perm.N an ereby avrhori a represanraiives of fhie Coun�y to eMar � tha a e- n o`d ropeny for inspecti pvr oses. - . � ' � ✓'� SEE REVERSE FOR E%PLANATORY UNGUAGE , SignaWre ol Applico�t Agent paie r �., -, r� ..,�!-:;. ._ .0 1. �R:�E"� ,�. f ,,,\ r , �—�� �� , . . ,�o,j,�o,�,��3 .. � . , . ;�. :� ' _...__.'.. . . . ._. .. . `. �. . . . -�ouy , . . . ,.,, , . . . pa�sod 8 I�ai�o� . _..._.. . _.___ . /��... . . ._ _ _ __... ._ .. ..,. ._ .' .. ' � � . ..� , ' -�aywnNasnoN /.' , _,. 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