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HomeMy WebLinkAbout1442A 1491A (8) i WORKER$'COMPENSqTION DECL.ARATION � -. -- �--- J'� � �he*eby offirm thot 1 hove o cenificow of�Q���"o,��f _ ��aPLiEATiON F�R BUILDING PERMIT � .� msure,or a certificate of Workers'Compensalion Insuronce, - or o certffied copy}hereof(Sea 3800,to6.�C.f - � COUNTY pP LOS ANGELES BUILOING AND SAFETV Polity No.__.. Company � ._ _. _ . � Certified mpy is hereby furnished. . -.�QR.AP�i�ANT TQ.F�u��.. . Bl1�l.RING ��.{ . \ . ..___("���,��... __.- ADDRE55-. - � Ut OCertified copy is filed with ihe tounty building inspeo- g�qp�rrC. �,/ � Fiondepwtmant. A�DRE55 � 3� ���- �Ss�ry ! [.V Dote .... AppliwM . . � Citt I'��Q�D � ZIP ! �� r/� � LOCALITY W�� CERF1FIflUE Of E%EMPTION FROM N'ORKERS' - ���8��++`- NEAREST - C(JMPENSATION-INSURANCE - SIZE OF lOT NOW ON LOT CRO55 ST. (This seCfion need nof 6a completed if-Fhe-pesmit is�fw o�e - TRACf BLOCK LDT NO. ,Hqp gppKR..� PAGE PARCEt hundred dollars�Z106�w less.) owr�R E2T Q2/L/fS�: l►f�li 7 use zor� Mnr � I certify lhat in the performance af the work fat which this (}�I �� j 1 parmit is iu�ad,I sholl not employ ony persnn in ony monner �9 � SVECU1l so os to kietome subjecf 10 fhe Workeri Compensotion lnws. ADDRE55�J.�� ��� -G�-Q�S�� � g Q� [�p�T�pNS �Q A CITYU 6�� ��� ZIP �f/��.. -.. . � GJ �Dute • �-�� Applimnt���� ARCHI7ECf OR -TEl � � NOTfCE T4 APPLICANT: If, nNer mcking�thid CertifirAle of �GINEER � O�STRIR GROUP TYPE FlRf PROC�SSED BY Q Exemption:-you shov{d batome wbjxl to fha Workars' . ���- Z� � Campensotion provisiorts of fhe�lnbor Cede,you.must-forth- ppoREu V with compiy with such prorizicns or tA�s permil shpll 6e - �� - �O .' � . � . �� �: daemed.evok�d. STATISTICAL CIASSIFICAiION nFT. COrvDO. f/� [aViRACTOR t�. Z tICEN�Q CONTRACTORS QECLARASIQt+4 . u�. �55 h70.�OWELL.UN�TS F hereby cHirm ftwt t am licensed under provisions ot Choptes P ADDf�55 Np. .��R� _ . . . . . . {commenci�with5ecfron7000)�otD�vision3-ofthe�Businessand . ��. . Professions Cade;and my-licenx is in-fuil#oree a�offect. CITY CtA55 _ �. �. � Ypi�ppTlOp� . . ..' . , �. ..- . -... . _ SQ.R NO.OF NO.OF EHEIX Licanse Numbet �- ".Lic.Class-' .•- SRE 5T0&IES - 6e.lniue5 --.-.—f3NE--- � YAIUATWN Contrxfar � � - Do1e � DES[RIFTION OF WORK r v F� A� o � �s�� . - � � ❑I�am eaempt vnder Sec. - � �£r� �C�� � ,� ncro� z i 4 G.2 f1 8.&P.C.far ihis reaton �PA1R --� . #� �• ��3 . ____ ��. USE OF - . �- - :- . FXISTING BL�C'a. �a � � - fl : -_ . : �f�1 . _ . ... .t a �.Q.� �._.. -$inCtqrc� - ..__._ ...:.�. APPLi�CANT. . .Qr ffl[f+.lss D�p.. � � - �K�fAI. .. . .� _ OWNER-BWIDER DECtARAT10N �7 ��e� , - DAT �f � •s sµ,,. ;- . �.t hero6y afficm thaf 1 am exempt from the Controclor'3 ticeme qOottE55 O-.a � ���� C..K-B-s:�1��1 �- Low for ihe followirg reawn jSettion 7035.5,$usiness and - - NNAL �G���_�R Profess'ronsGode). _., .. . .._ _,. .. . .. _. _.._...--- -_-_._ .__---------..___ ..__, �:-y�r`�_- -- ..tt''''77tt ._ � � - BUItOitJC �_� 1,os owner of the p�operty,or my employees with AppRE55 .. ' - �- woges m their sote mmpensaeion.vriil do rhe work nnd� -- -�--.-..-._... ._ . the structure is not immded or offercd for wla(Section ��`��Tr � . . 704A.Business nnd Professiais Gcds� . . .. -- MOVING � �L .. � 1,aa owner nf Ihe property,am exdusively contmcting TRAC70R NO. - . witH IiCEftSGd[ontractws�to cOnSFrVe1 tFfe pfOjE[t(Se[- ADDRE55 - � � tion 704I,Busineu and Professions Code). - � - - - � REQUlRED TOTqt T K �� --�`- - � � - . - . .. -EONSTRUCTION IENDING AGEMCY_. . -�SET en�c . .y�. _byyy.. _—_PROP.-lll�-------� -W107H- � -._ _ . z`} �i Y,1 h !hereby affirm thai there is o consk�ction lendin9�^�Y f� FROrvT . . .__tha.parformance uE the.wnrk for which fk�is permit is issued v.t. . #•+ • • • � (Sec 3097,-.Civ.C.J, SiDE r.�. 1 „6 l 7 5 ...lender'a Nama . . ..... . . . ... . . . . r ! iDMn Raf.A P.C.F��S Permit ha �J ��-�1 • • •� �.j 5� m lendar's Address � � � I carfify that 1 have rwd this opplicalion and stata that ihe issuance Fae 1Q•`$� �on,w r�c x . 0 9.0 4—L�? obove iniwmntion is correct.1 a9ree to comply with ol�Couaty invsni�ptfort h� � �/ � ordinances arrd State laws relofinQ l0 6ui�dinp consvuctlon. . iotal Fee �+ 1 � _ � . and hereby authwiza rapresenta�ives of this Counry to�anter � ���Px"`.� � upon�he bovo-montionod poptrty for Inspection purposss. - . . . .... ... . . . g ��^�/ fif NiViRSf i0Y iXMANATatY IANWAOi - . � -�S notw�of.App�fmn�m�Apant . � Ooh � .. _ . � { � � � t � �2r �� 3�o z'� � �` ��� � i�-1�� -Y - _ . ., _ a - . -� �: . 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