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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 . �, S:qnmure of nppum��mXgenr pob r . � . ._ _ " . . . . . . - .z -`.- R � r G .* "�s G .. ^. . b k . , . 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