HomeMy WebLinkAbout0891A 4748A WORKERS'COMPENSA710N DECLARATION = �
1 hereby pf4irm tha� I ha�e o certificole aF�o�5e�, io self APPi.ICATI�JN FOR BUILDING PERMIT �
insure,or o certifica�e of Worke.s'Compensation Insurance, _.
or a certified copy thereof�Sec.3800,lab.C.) '
COUNTY OF LOS ANGELES BUILDING ANQ SAFETY
PolicyNo. Compony �
� Ceriified�o s hereby fumrshed. F�R APPLICANT TO fILL IN OUitDING � ��
PY� AD�RESS G�O
� Certified copy is filed wi�h the couniy bu�ld�ng inspec- qD�RE55 ZW�p(� F3RpICEN FGA'�}j�R �4t�� �
tion department �
Date Applkorn ciTv U!/� O►IC 1tR ziv tp�p,�itv
CERTIFICATE OF EXEMPTION FROM WORKERS' SiZE OF�lOT IR1ZFi LAR NOw ON�LO75 � C OSSSST. �
COMPENSATION INSURANCE
(This section need nof be completed if Ihe permit is for one �j ASSESSOR
hundred dollaro(5100)or less.� TRACT ��� BLOCK LOT NO. �6 �qqp gpp�( PAGE PARLfI
TEl ( Uy�,ZONE- hV.V rf
I certify ihot in ihe performance of Ihe work for which this OWNER V 1}E �N�� (��:r . NO. ��.0"3 �
permit is issued,I sholl not emplay any person in ony manner �t � ���A� O
so as to bec me subject io the Wor ers' mpensa�j n Low � P.DDRE55 S/f � �O� CONOITIONS �„�
�Q CITY ZIP �
Dafe 3 V, Applicont � ARCNREC10 Ro4ERT K.t-A�RD TE�� O
NOTI TO APPLICANT: If, after aking Ihis Certificote of DISTRiCT GROUP TYPE FIRE PROCESSED BY
ENGINEER 4 Na���I'�4 3 �ST.
Exemption, you should become subject to ihe Workers' � q�r `' � W
Compensation prorisions of the La6or Code,you must forih- qDDRESS � t1. ft�/kC AVB �� �T� �� �"3 �l1 f � ��
wi�h comply with such provisions or this permit shall be iEL ! r STA715TICAL QASSIFICA710N APT. CONDO. Z
deemed revoked. CONTRACTOR NO. �n-3�r1 �
LICENSED CONTRAQORS DECLARAT�ON ��� C1A55 NO.�OWELL.UNITS
I here6y affirm thai 1 am licensed�nder provisions of Chapter 9 ADDRE55� 2 �.�� �CT No. 501�3
(commencing with Sec�ion 7000)of Division 3 of ihe 8usiness and . �-r� q /� ���, SEVJER N'p'P ,
Professions Code,and my license is in full force and effect. CITY A(�1�� �A 1 �1� QASS L3 BK � VALIDATION �
SQ.FT NO.OF 1 Np.OF CHEGR
LiCense Nv 0� Lic.Class� SIZE STDRIES l FAMIlIES � ONE
' (2) P�Ep�ppn NEw VALUATION I
DESCRIPTION OF WORK
Conlractor • Date (' ei S �O l�� /
�I om azempf under Se[. "V v ,7� �� p d� A�R , F C��•1 ��
8.8P.C.for this reason REPAiR ; �'`� � ° `�`�
USE OF 7
Date: EXi571NGBtDG. SII{�ryL� rRHI�-�[' KE�. ��L I • � �7 I.f���
Signature AF7UCANT I - p TEI. HNA! �S
OWNER-BUI��ER DECLARATION PRIN7 W�RR�Y 7V0� 'K1T1A1�0. "� 3 DATE � � ° � E' 1��"`.�`
I heroby affinr�thot I om exempt from Ihe Coniractor's License � qDDRE55��3 � ��17�D AvE. CL,pR�" 41�T
Law for the following reasan(Sedion 7031.5, Business and H FINAL ��.� 5—F&
Professions Cade): 6Y
� 1, as awner of ihe property, or my employees with ADIDRE55 � . �
wages as rheir sole compensation,will do the work and �
• the siructure is not intended or oHered for sale(Section IOCAIiTY
7044,Business and Professions Code). MOVING TEL �
� 'I,as owner of fhe property,am exclusively contracting CONTRAROR �� � �
with licensed comracrors to construct the prol���i5ec- AD�RE55 �^�����'� t���r'�.
tion 7044,Business and Grofassions CodeJ.
� CONSTRUCTION LENDING AGENGY �Qgq� vnRD HWY T�TA�pR���� WIpTH }' @". '" '. - .
I hereby affirm thor�here is a construc�ion lending agency for feONT '
the performance of the work fo�which this permit is iswad v.i. - I a'L��:�`�+i(:
(Sec.3097,Civ.C.j. sioe '
P.i. _ �, ���,�,�,;,;:
Lender's Nama
/ 7 IDMA Ref.k
m � C.C.Fea f �P/' Vermit Fee � ��.`J� —�. ,
lender's Address
� I certify thar I have read this application and state that the Issuance Fee LDMA P/C M
above infwmotion is correct.1 ogree ro comply with all County Investigmion Fee
ordinonces and Stote laws reloting la building construclion, To�al Fee '0� IDMA Fmm.M
' � ond heraby authorize representotives of this County ro enter
•pon above-mentioned pr r for inapectiOn pur oses.
EZ9S(��X �as6�i� � SEE REVENSE FOR E][PIANATORY MNGUAGE
� Signafure of Appli<onr or Agent �¢ . . ��
� �r
ALANS TO APPUCANT IfiSPECTOR'S NOTES O4VNF;Kd�UI1.D4:R DI{('.iARq I lOh:
_ I h eb� rffi� i o I � ia i �i 1 n F� . a f �
Tn� Raturn�d � . � � W�� px �� L �- ! re. +.i .� .. > 15� Oas..,
�/l /1,�.��., y,�'�,aR' ' ,,
' Approved �- --- 8r<srn e and/ �) r s i i! nn�� ft untt a!�-E
,— _.�'..,. —
�Nc�. Datn Na Dale � ��y� � (.��t W�� � C.,d p���i�l re y . u p�r rrt l v t rk �� J 1 !
-- _��_ _�� _ c_.�=.—�r=.... �-- orr.pnaruny t �t r,f' � tt�cti / � �cs
.,� .. � /1��Y•�•L w C J ¢. ' e.�'��-`C�2..a: �b��a�plr�awr� s I p r 1 t t J�r,. q J.�e r e
. . � __.___ � �Se Pl L�-+-^] . . lhalGruL.r J/ �rn a tt fl.(,r u-r n /d f
�._ . �—.—__. .—��j�� 1ru�tnr:afrrenc !a� /(/�d�if .1/(>m oinKurt{ 1���
_� 'Y
���T ��� _ .���4�'�.¢c _S�*��!Q� uGl� tir�n i00(7/nf U s" 3 r�thc Buv� �s� d 1 � +..
_) / � C J 1 nr tbut h -�, empt tl E �Jrnrv� !t1.b�+� J thr
_. Y(J�( � �'/�f a!!.g J erenrp+ in,, � 1 t n/1 �-� '(7 f r 5 hi-
' � � Requlred � pnta llecwirsd � a++)'�PPli�.+nt(or u permia t�Aj�..ts fl+ up�li�unt t -�n.�e!
Approra9: }--� , Panul:y o/nnr n,oru tban/� -h�sodr.d dntl,ars(SSntlil
� ' '��Ycx � N i or APProvsd . a . .
� . _ _ ..�_�_ _-__. ___ �.�� I,as u of the p o� ,��� >� . .:.F� � -i�
�• rcnre . wcy. oslhe s I �.o �pe s�fo . i �hH --�
�� ��� rha tructure is not� iended o o(f.red t �o� ( e ��Ad}
Vrh Depn+tm�n� � - � 8ruin ss arrJ Pr�/ss�or�s(�d ,71 n-( t�7�r s 1 aen a
� f.uu darc nrel appl�.to ur�o�vner f h i�.-t'u'h hur!?s
(F:re��evcnmenf � . � . . . � a,.:.�... . y.., , . o np r e-a tA �i ro�ursd u!>o doc>s h u o k b: �. 1!!r
�„_ � , ,_ ,. . �::�,., lbrnu,qt> bis nu rs crerplr tvea, prr r:deJ tl u� sud. vn-
i ,.. . � .. . .. �
G,�d��nq . � � j proverr.ents a.c not inrender! nr �// rd f��r f f!
- - . . . - ..... . , [rmocrer,tbc hu:Jdrnq nr i p oi crna xt r.+nl�i a a[hin.�x�<<
�Gaol�g�cai _' . . . . . . . . . Yeur of mm(�letion, elE u-n �-buildr•r itil! b't�.t�ic,
burden o/ymertt�;LGa!hr Ard nof ht it+ �r in:pr<<e��r
r---"'� � � � - �
P�4estr on RWx��a� I � . . . . � ' . . . , . . tbe pur/�nse o/s�1e/. .
Feoc•a)(Cnncpyl � - '' i,os owner of ihe p opariy,am c cl s��e?y�o�unc
i- __ �, , , . , . � . , --- ti g wnh licensed conrracro s�q ronst rrh. prol- �i5ec.
� � I . 7G44j-1?usrrsess anJ Ym/eas�ons C`od �h• Cunt¢1nr's
K :�� .pecFon
� �rc (Mnsonry}�Weldina; � � � Lirercse l uu Jnes not apply f��an ow aer J/+-uj�e ty u�Gn
� � � � � burl�k ir F�nproe ea lherei�n,und u•b i nt� t,J s e�;Ai
�t.�p�� � . , . Pt leeis u�rti a cantractrir(rl lieenned pr�esaant to tGe �
, S._.�_.��{._._._..._ . . � . .Cuntraetnrr Licensn f.au^l� .
I_.�_�Fn�^���.'. .'_._�� .. . . ...' �� I am exempl under$ec. .B.Bc.C.for rhi;
____._ -
� �-,- repson
� � � � � �.! . ,, . � . . , . . . , � . . Daie Ownar.�.�
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