HomeMy WebLinkAbout1535A 1650A (8) lold�7� � �. �i' • . �
WORKERS'COMPENSATI�Y DECIkRAiION � ���-� -- ._� % f � �- - � � �
� I he�eti. affirm-rhar�fia�e-a-zerthscote-of-cansen�-to self ----- - �
'nsurr� or o cerii[ico�e of Workerz'Compenw�ion Insmance, APP��C.=,�ft�N-��OR- BUiLDI-NG -.PERMIT
" S�`�.�riifi�ed,c�apy thereof_(Sec.3800,tab.`C.)
Policy Mo. -�t (Compony �lL���F�/d� COUNTY OF LOS ANGELES BUfLDING AND SAFETY
� Ceriified copy is hereby fumished. FOR APPUCANT TO FILL IN ���D�rvG �i •
Certifeed copy+s6iled wiah the c nly buJding inspec• --- -- g�y�tDiNG-- - � � ADDRESS
/ ----*��.-�,-�/�-. _ ..
� 1Gon departmenl. . _ _ ADDRE55 / �3� i�CL�J'G�.-�/GO$.r/A.7 �
Qate�Applimnh C�tY �( ,t/fj ZiP �Q�A�ITY
Q. ERTIFICATE OF EXEMPT�OfV PROM WORKERS � NO.OF BtoGS. NEp,RESi �
''"��I�O� CAMPENSATlON 1NSlIRANGE.. _.. SIZE OF LOT NOW ON tOT CROSS ST. -
( �s se. ion need not 6e mmple4ed i4 the pgrmit.�i;for_o�e iRACT eLOCK lOT NQ. A��R
huadred do�lars(5700)or less.j- MAP�BOOK VqGE NGEL
�� �C�-P6� �z�,: �
i cenify tho�in�he perfwmvrece af the work for whfch this 6W�R ��'f �- rlp. � s i
permit Gs issued,t shnll not employ ony person i�ony manner qppREu 3/�c��Q S f+� ���� �
so as ta become su6�ec�fo fhe�Worken'Cempenintion tows. +A CONDITIONS
�ote ApPticant _. . . . CI7V .lJ! o . _ . ..._ 21V . . ._.__ . . .__. _. �
NOTICE TO.�.VPUCANT: If, ofter moking thia Cer_t�frcate-of ARCH�TECTOR T�'� DISTRICT GftOUP 7YpE ryRE pQOCF5SFQ9y
Exemption, you ahould becOme wbje[t to the Workers' ENGINEER Np. �Q�ST ZOI�E (
Gompenwtion pronsi4ns of the iphor,C.ode you�mugt forth- qppR� � 1� �� (
witb comply with wcb pror�s�ons or this permi(eholl be '� ._ -� - :
deemed revoked. -- � - �` S �� � / STATISTIG4l CIASSIFICATION - . CONpp.
CONTRAQOR - �r 30 -
��IlCENSED CONiRACFORS DECLARATION � ' f ��� -�-�pp,-� --pyy����
- I here6y�r QFF�rcm that I am ficenxd urider proviuo�s of Cfiapter 9 ADORE55 a,v - ��, ,,,E,.33 iL y
{commartcing wid�Sectiort 7(IODJ af Uivisian 3-af dre 6usirmas�d LIC. ��R� . . . . --�..�-._.... . �
.. Profeuicns Code,ard my license is.n full force ord effed. C�TV �ia� �- Ctn55 � VMIDATION
--`--sR._.. _.pG.-. ... . .
7 y , / .� SQ.fi. .l�1 NO.OF—... . NO.dF ` � CHEQ(
�License Number�L,2.L3f2.=�Lic.Class� SIZE � 4P STORIES Z FAMILIES / ONE .
�r �VALUATION
ContrOCtorr�B- I,US7A-LG'FW�Cpa� DESCRIPTIONOFNlORK � ❑ s ,j��6cf �
aoo � � — �
- �1 om exempt under Sec. � � !a E4/`r��'� �
ALTER
B.8 P.C.for�his reason .-�F���. � . . . � - S. . . ��:}�✓.�h
REDAIR
� Dnte: USf OF .T ❑ - .
- Ex15TING BLOG.i�it/'C1f-�-/w.� DEMOL _- - . � .
. Siyoatore . . . . ... .._. a,vgliCAHi_ . /�. . . iEl. GQO �..FNAt N� • C.?
OWNER-BUILDERUECtARATiON ��HT J���''� �-�`� -
�hereby affirrN that t am exempt from the Comractofs license - - �� � ��� � ' •`���`�v
law fw-the fiollowing teason(Sec�ion 703f.5,�Business and AODRESS ���CL+} d���� _. -
Professions Cpdej: .. .. .: . . ..... . . R B� • e s�/j�,��-,-�.,�
BUIl01NG
_.._._
� i,� as owner of fhe�propeNy, or my emplayees with ypp�5,5 __ �Q'� Z � �
.. . -ruages os theu sola compGwsafion,wilk dp ihe wwk and � ��qLlTv - � � . . � -
� t:Fe structure is not intended or offerecl for sole(Secfion .
7'Oa4,Busineu and Professions Code). hnOvirvG iet.
� 1.,os owner of the properry,am exdusively tontroctiog CONTRACTOR NO. .. . �
with licensed mn[roctors�o consnuct_[he prol�t..lSer AppREu . .. -. .. __--_-_ ___.._--. __. .-. . ._. . .
�ion 70N,8uaineu and Professicns Code). � . . . �
E IRED-- - - TOTAL SET �'� ' .
CONSTRUCtION LENDlNG AGENCY_:, , -- �ser.eE,CK-� YAR� �` vRop.uNE w�07H - -
1 hereby affirm thot there is o construcfion lending ogency fw � PRONi z_� 6 5,(`j�'.
�he yerforrtwnts of.Ihe.work_fw.which.fhis pecmif.ia issued p.�.
{Sec.3C797,Civ.C.). . . _. SiDE . . . �y�s • o s �
P.L
tender"s Name� � • •6 g Q�
N L6MA Ref.M -
m Le�e��i Addfess - ._ P_G Fee S r Permi�fee_ \ _ •����r�x
3
1 ceAifyr thot I have read this applimtion and sto�e tFwt fha iss�ance Fee ��� LDAM P/C M ,
� obove i�n rrtwti ia cortect.1 agree ro compiy with-a�YCoortty -"- �meuigarion Paa /�, . G 9,� 9—H�i
'q ordino s on fote(ows reloling�o b�ildi�g conskuclion, Total Fee `7 Q
LDhw eerm.M
R -and eby ul oriie reprqentotives of Ihis EauMy ro enter ---
u e entio d properly for inspeetion porpoxs. ,
.. - . . V . . - q/3/P G ffE tEYilSE FOR EX►tANATORY IAMGUAGf .
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