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HomeMy WebLinkAbout1214A (6) � __ _. . _ _ _. �. __ __ _ _. ._ ._. .— --- --. WORKERS'COMPENSATION DECIARATION � � � ' I he�eby offirm that��a�a o�e«��,�a�e�af�o�5a�„o se�f �� � � � qpp�lCA_��N � FQR BUILDIfVG PERMIY� � � �l, insuro,or a ceni(icote of Worken'Compensation Ins�ronce, or o canified capy thereof(Sec:3800,tob.C.) COUNTY Of LOS ANGELES BUILOING AND�SAFETY � � Poli[yNo. Company . n � Certified copy is hereby furnished. FOR APPLICANT TO FIIL IN'' �'����' � +(,(�.eq p-Q.L.,� i(,d.� �/�, noorc�ss � Cer�ified copy is liled wi�h the county building inspec- BUiID�NG � � tion departmenl, aooRE55 � Date ,. �. APPlicant . CITY .. 21P �O iOCAtITY 1^�C.Cc�...... Cl� G��— CERTIfICATE OF E%EMPTION FROM�WORKERS'� � '� ' ! ���etoGs. � r�.aaESi . ...- . . . ._. � _ COMPENSATION INSURANCE � ✓'� SRe OF LOT 7 F NCW ON LOT CRO55 A. (This secfion need nol ba compleled N ihe permit is(Or one TRAR BLOCK LOT NO. M�qp j � �PAGE PARCEL ' hundred dollars(f100)or less.) . � T,� � � USt ZONE � ct I eertify�thet 1n tha performanee of the work for wblch Ihis�� � OWNER rw. � �M' p�p . �� � T �, parmit la bsued,1 sholl nol employ any person I'n an"y manner � ����� � . • - - � d so as lo bscome subject fo fhe Workeri Compensation Laws. A07RE55 CONDITIONS O . , u oa�e ' ' naPi��a�� ..,' cirr �A N z�P _. . - a � NO1ICE�TO APPLICANT: If, ofier moking Ihis Certificote of NGHEERIO� t� G DISTRiCT GROUP 7YPE FiRE PROCESSED BY Exemption, you should betome•subject �0 4he Workers' 1 CONSi. �.20r�E Compenwtion provisionc of the Lobor.Code,you musi forlh-. qppttE55 O � / ' � `� �� ��. �� d winc �omply wiih auch provisions or Ihts permil ihcl� be �� - - � � . -7E�, /q STATISTICAI QA59FlCqTION Avi. Corioo. � deemed rovoked. � • _ �pr,i7pp�7pg � p�p_ . , � � - IICENSED CONTRACTORS DEQARATION� . � � �-����, � C1a55 NO. �" DWEIL.UNITS �...'(ommsoc n1g wi h�8ect on��70005of D'��v iion 3voi he Busnei ond _ AooREu C `+o. � , . . SEWER MAP Profnssiom Code,and my licenu is in full fwce and eHect. CRY {���i��`� 55 ' - � � � - VALIDATION - � .. � � . .. . 50.F. CT NO.OF CHECK 8K. PG.�S . . . licenseNumber Lic;Class' � SIZE STORitS ' fAMilLS ' daE '� � � . VAWATION .,'� � COnt�aclor D010 . � ��RIPTION OF WORK . . � . ❑ s ,^ ��,y1� - p .� c�k. ^°° ll L/�� � �1 2 1.4 A I am�a�mpl under Sec. � • • AITER ' B.BP.C.for this reason _ ' REPAIR � S . ' . �� � �2 J . ._. . Dafe: USE OF DEMOc ❑ � • •�Q�3 ExISTING BIDG. APPIICAM • TEL � V z Signalure . . - �iM .�. - . fINAI i.._ . • • •%�.� o � CLYNER•BUILDER DEC[ARATION DATE � . � � � � 1 har�6y nlfirm thot I 9m eaempt(rom�he CaNmc�cr's Ucense ADDeE55 C / � }/�_ FINAI - . r'�I11J O ..Cd ��1y_fi 77J �'�'/7 Low for�he followin reason(Seclion 70�I.5,Business and - � � '�r- �,J 'Professions Code): .;. . .,� ..�. - . . . . —a� . pl' . . . �" '� I(� ( � a���o�� ��Ae �ur�nur,�K D � },�. . I, es owner of Ihe property, or my employees with AODRESS woges os their wle tompensotion,will do�he worA and T `p the strucWre is not intended or of(ere'for tole(Section ����TY 6 � `,��\�� �,41� �\ � 701�,Business and Profeuions Code. MOviNG iE�. '�� � L n 1_ � QI,os owne�of Iha property,om eadusively comracfing C RAciOR NO. _f��`` . �� ��� }� b�jZ84��� WIIF1 IiCen58J[OntroqOrs f0 COn3V�d IhB PlOjt[}(SBC qDDRESS �- �A•� �1(!�/��Cw7GH [QGtS'C �� , tlon 7W�,Busineu and Pro(assions Code). � � �� '�: , REQl11RED yARD HVJY 10TAL SET6A �( " � CONSTRUCTION IENDING AGENCY "'� SET BnGc atOa.UtdE 1VIDTH f J� I. � �V����.1 �RT�I�. � I her�y affi�m Ihat Ihera Is o consfruction len�ng agency for FROrvi •��-�.�7/�F �p y „�£����,J �^ Ihe �formance of the work(or whith thi� rmil is luved P.L. �/� " �/� H � (Sec.3097,Cir.C.). Si�E .. T e . . .., v.�. - J��IY`f �4�- tenders Name .. - IDMA Rel.M . $ ' ' . .. , � P.C.FeeS O•I Pe:mi�Fee �-. ,...... ....- .^`? -r/ �S . - Lendar's Add�eu ' ' • -t� � � 1 certify that I hove rood ihis applicaticn ond slo�e thal Iha . Is.oance Fee � LDMA 7/C 7f ,�����W�N V D� � „ above Informotion Is cwrod.I ogree to comply with all Co���Ny �nreanga�mn Fea �`�'�1�'`fD,� g ord�nances and Sia�e laws relating to buildinq consVuclion, ,_ T"ial Fee IDMA Per .M • ���� ��� u aod herehy authorize r sentativn of�his Counly to eMer � � � � �a � upon the obove-men o property for inspecfion purposes. . . � . . . .. . _ . . ..� .. . .. ..� _ M� � � � t � W t9�R . , _,. _;. _.. .. . .. _, 4/ �� S n � ) �/"D�GC� p�j,p_ SEf�EVERSE fOR E%N\NATO[Y LANGUAGE � - • S� S u �,�_I.•,�r � Slqirolure o(ApbLcanf cr ASent. . .� . . , .. . . . -. . . . , . ��_ �~ �� '� ,S�Joh!'��1KA SHe.AlA1G AW�c.r�l ,_.�. ,-----�- -- � �iS.'+v��;-�WE4��� G ' _ s: , � _ _ � _�` I � , _ _ . , . '.�.r ' - . . .- . .l ,. �. � ' �. .. . - .� i . .. t�'� ...t i , . ti.._: . . . . .. � � , , , ' ' , . i . � � .. :d�. . l . • � .. .. • . . - :��. . • , . � . ._ _ .