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HomeMy WebLinkAbout1511A WORKERS'COMPENSATION DECtARATION i ne�eby off •: ��•;:• ' •.:.�r r :�r•rimrc of ronser:r :o selr , � insurc,or n c�..•�:•,• .•i..,'1�•...�•:';)mCens'a'inn'rs�.ranre o. �l6AGa3�.. . •... -. . � , . .. . . ace•��f�edce;..�.,`���,.. �Y� �taoa;aeveian SE�iilEii ��N.�F�OR �Ei�I1111T� . .,r. ?E:,'i: :nb C.i APPLI�ATIO PoLcy .� �—...`'Compo^y,_.�'I�i•_F�.� .—'__ �y i , Cer�i�� p�i:s".Fe�eb f��n�shed ' �GE VISP�SAL �,Cn�,�f:ed mpy is i�led wilh�hr.courty bu�ldm�7:nspec!ion � COUNTY QF LOS ANGELES � � SUItDING AND Si4F�TY" '�"�T���M��.�M�� ^` F � nenor meM . . .� ... , ....__..�........w.,..�..,.»..,...�..:.,.,..M,,.,�,.,.oN,+...,.�:aw� ,w -� �::�+: "wx,x;,�a,:,. Dn��,EI ZO S�A ����o��_ Freeman _ ------- ...,, �........ _ 1__.. P FOR APPLICANT TO FILL IM CONlJECTION DATA .' CERTiFICATF OF EXEAAPTION�FRCS�v(�JORK�R5'. . � �� ::.1�n[� Z q [-i`' ,. :u :t=.. ..., COMPEN.SA?ION INSURANCE ' +%�4�ss � ..r�y-G .S tP� " —�'��..-----�'��--�-x--- � ------ _........ 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ROA�PERMITNO_� __' NO7iCF TO APP!ICAnJT: I� of.r.r��m�kin, ih�s�Ce�i�f�cate Of py p C � AFFIDAVIT WANER EASEMENT RECORO WSTR NO. �DATE 4 �,5rmp'io^, you s�c�lri hr„ome 5;.6�ect lo rhe Wor4eri --� �'dV1Y1?y "h��.� c�,a,o1�07-95�:_ �.a;. .:'nc: •pensr.11or o�ovis�ons oF�he Ln6cr rade,yo.,m�s•rnr'hwd'! ,,:st:r�r.e „��'f iv.� Cusr WItlERiNG - - � � � �� � np'y wiih surn ornvrswns or this or mii sn�!I be decrnea ��� " C��7 . �e��akc�1 S.f:C< •"' �J 15a _" ......_.._.�.,, ._ ..,.� ._ ,�......... ........ . cf:.:-tN.'.ROACI-fNfEIJf ____"_ '"—_ ' �__ x�..." LICFNSFD CO�v'TRACTORS CFCLARATION� �o;`i e r.cs � '��� � - `�erebv�:�°�"^�'hol I nm hcensr:<:u+�;i.'•^.:: ,,oi Chapte.r --'-- -- � �- ' 9 ;comrr:enc�n w��n Sn,-�:or 7(;OGi �� ' ������ �,�f•ne Busi- ��� '[� � )I� : V(;::.:\.ii US [� C] ,: .. . �::II:\::i 47� L.�l�sa '-A'k(iF5 ncsz nnd Prefessiors Coar. �rd r+y �,r •� �•.li Fo�re en�i — -_--—=—'-- - . �.;, _— �_ ..._. . . -_ eifec� ,7/� ��7 , '.U�v:.:';:u F'RL'^'�'��n �i�rJSTw .`��\k"0\'.'•IA4GE"Fi ..... ....... . } Li:ense Nc^iber.yJ Y84�1___!'c Ciass__(y —'—_"-- _—' �3.�-- .,�:,�«> 8225 BeecriVroo�Tr.. '�•,+b�+s:•:=nr-r= � Co••rmcror�'T22D12D.---Da-e_8�2��86 _ ----`- ----- .s=+ri�c r:c_, .,,a: —'r—uc:;s,�.�3v.... V CIiY jn iEL NO � e ._I'Lm C%efn u^.der Se• c?;:•e Lq.Cr., sraTs � ,1,l�ogi� !'�T A BK PG o p , '_—__'_--- i'�.�5'�;, "t 4 �'.55 � l� ___.' ' "—'—"'— ' _" . PIL•f'1DI�I(3CCC�P(]9d'O�SeC _Ufine '^ __,�-,. "TlC40fbYORK ' . :ItiA_—" _' "'�"—' W . .--- .r:,tx;a.�v,nn.,-n �i:�.ic� '"_ 'JE.ti=F:.-'1 A K A Code*or^�e�cl�nwir•.��eason _ ' �.�' Q l�^�Z�8� V/�LIDATI N _,.._'--.._,. y ..—� . �i�;:,:.�c c��:.n:v'•!;1 �".'_ ' s.,r.::.eox<�s •i. i -�:. � ___' _'Dn�l.__—_"__'_ :(:F A:r'::NV"'\•',r^ ..r_�1_ (��\� 1`� i':;5:�.. .yS-fr,• ___ __ I _'_�L� S',Cjf'a:Jre____ . . . . . PlVi^n�^.'J`.:.8,';'�C2 ' OWNiR-RUI:CERDECIARA71pN..... �� ��S"�.°F' - ---- --- � ' :�•e�eb ff:��•ha+i:�,r:exempt irom rl,c i:�'+�•- o, a.:�§ni.,;��_ t y a Cr.�ra.tor's l:censc � ,^[igo=c��j:B°v.:._nV��^..� � � � iov,for��.r,fo:lowinc•epson'Se:4�n 703!5,B„isness a�d P�o- .-..�rp�a.-�:�a nec�;o�.p.isv ----�_— �' � {^i i�� �� 4 . �,iCriS(',,. _ -:.�k r:2'.i;I:.SA.c�5�:;• _�— % {ww a�. . ""_' _ . I �.as� ,:..."�.,..••.,r'. cr,r.y emr.lcyces�,vi•�,waqr s r.s }r.0 c�o o.� Q :�� ���r �, r '�•�ic�sahon,w�.'I nn r%+c work nnn'tie s'ructure � •or c`Ec•ed tnr=a�e. ;Sernnr,7044,B�siness — � °D °2 �y�J i, .,, ..,��,,, — '._ ' rua Pro�ess:n�•s Code� �WI�ER�S Permit : 1Q�5� �. i aa o•Nne�of'r.c propr.r�y,am ezriva�e y cont•aa:-iy�..rr AUTHORIZATION LTOTA�FEE ��?' '� " °��''�u licentied con-rnr:e�s•o ronsr.:�U!^e ormr:!;Secr�o^7044 I HAVE AT'� i":•.' 4:::\-7n;' :^. '_:�IF7%i\\F9C�,�0\C44,'::t i'. o[, R�.ISi'IC55��(I�IO�CS�Vi15 COtlC: CONNEC�'•1:t.f��).'�';�::i aF^i%.S'\•:^..:.-.k i'^T�.F-..i..r'$f:tCG Y��'G Q"�C%V CONSTRI:�TION LENDING AGENCY ' ' " ""�' � � � 1 nc•r.hy nfhrm �:.ao' •hr.�r, is a :m�s�n:Uio•• ir.nd�ny age•,ty S,C:P.cD'HS__.�� :;AYy7-__�__Y� � .`or �he performa�ue of ine v.�cr4 fo� �edno: liiis :�ermrt is ""'^``'�k v' 1� �,:,�.u.�n:;t.-r�•I.Cf'_`/—"�__e J,r�1.��r*'L C✓ --- �ssued fSec 3097.C�v.C� ;,._ir:: ' � : �e�dP�'s Na..�e . �.. . • , . �r.nde%e Address_ ' �..,�,.f.«w,...,..,�...-..„.m. ..�,......�....w,.......a«„....�.�.,«,,...,..,,,..-.,..�.�..«.,...... � . ; <er..fy •'r,n• I nove r�o<! r's�nooliir.t�on�d sic•r. •hat rhe.•.••.�.YM.�,>.-,•.�G,.W.�,x-..«,m.•,•n,.�».-P•. _.....,�•• � .. �^ ._ i0.Y.. ::bo�c��fornio'�on�s,o�•ec�.'o,r,rec�o r.c�nd'v w�'n a�!Coun'Y ordinonces and So�r. Inws�r.anl;Y•�ng Plim6ino n+d Sewers, am!�•nreby a�'nonxc:represr.r•nhoes ci M�s Coun•y �c enle.� �non�he anovc-r�enno�+r.d oroo^�ry for;nspeu o�i o��rposes. �-���`'p++-,y--�.-�� �'/Mc,'t�:.w'----c��S-��. �,...... �'idnnf�.c;�/Pr.:•ni��r.r 7(i'r SEE REVERSE FON E%PLAF:A70RY IANGUAGE . . . � . ��... ,� . . . . . . �mew.rn+ws�.�. a�axa+�..p..A-,.--�...a.rw.�1.=.::�.,..:::�... �......,..:�i �„ . .,..,:..�..:. ...... ..............,..,....T........�..a..�..ew