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HomeMy WebLinkAbout1524A _... ..... . .. ..,..._.. ....... .. . , .. ..... .�... ... . .. . _. __..._ . WORKERS'COMPENSATION DF.t[ARAi10N � � - I hereby afiirm �nn' � haee a <erti4�ro!e of wnsen! 'o sel! . . �, . � � . � �nsure.or n cerr:6cafe nf Wo•Keri Co:-ioensa!ion Insurnnc�,ar - �anaao a«�.�t��d copy rhereor(Sec.3800,!ab�.�, ������ ��� ���� �pp���q�0pty �pR PERMIT P��.,�:.,-�76�I"r,,...:::,-, ..5�..__1'�and - -— �a;, �.-:;,. ...,/:�'�����:• �.•�iishcd SEWER - SEWAGE DISPOSAL ��Ce.iifie�cr,py�s+�u�d wi�h�ne roi�my boudrt�� nspecl�on COUNTY E7F LOS ANGELE$ BUILDING AND SAfETY dv orlrncr• � .. . .. ....,,...� � � p ._. . .. . . ..,. . , .,+� i.a,o-.,�W..M1..��:,,.. . � .,r..i......,..... ..... ...,.. .. oarc_ 8�2018�ooi,ram_._Fr28IDa.T1 . FOR APPLICANTTO FILi IN CONNECTION DATA ------- , . .�.�<..,�:,. _... .,.. .,. :.._.� . . , CFRT1fICATE�OF EXEMpTIO�:�FROOM WORKERS' • ��,; � � � / ����� ' � """' COMPENSATION INSL'RANCE ar;^ir=.5� �' (y / �''^ �h x�'�� �2����_J����� ..� ;T�is seC,on need^e1 bc�compleleo:f;hr.work�nan:ved by:he ��— --' ..,Ww��'.: �+��� � � •., �n T v;.�.q'�kFfFtf•• '__'._.. pr.rma;s for one�unnred dollars�S1CD'or letis;• ��"" ' �11��1_—. '—._ _"_._ ,r � <eriiy �.w; m ;he pertiormar:c o1 �he work ior w��rh•his vrn.i=' � �j �=v'i-..�r._.. ....'_ "_"""_ _ ^..-+� __'_'_'_ .:o�ss- �G6�Cli.?_ . . .: ne��r�t is�ssoed,:siaJl no�emo�oy any person,n nr,y�ao��ner � 'J •� � �� .— _ _,. . ....� .... .......,.. so ns'o bewme suh�ec!lo'nr.Workers'Coi�pn�aanon�a•�..,. .,. fINDEY GRP '� ��% � •.•`+`• . ,.... . , �o�:�v nc r,:r,.o d,�{ � -' — .. . .....: .,......, ,, , , ,,::.,. /� 7, DO'C___—'AP�IiCC��lr__ . �":f.4�5`, �Q BVX_J329 _ "4..\K[i�.5�:�'C iCA:F�R'�"\Y: . ..."- ._.� . .. . _��. . . . � �Y Y prov s�nm.n�ihe me su'c�;�,c•,. . ... _ .. ,.. .� ss . .. .. . NOTICE TO APPIICAN?�:�ii. ❑r�er rraKing .n�s Cerl:firatc cf ,., 8-.� .� ��, r•..+��re �...•:;�i tE:^an �iTx n::.. �7a-:'.�. Covina �� ,:� _1 5�-Q5 i �� I . ;mpnon . t to Ih:c Workers' �� :r,.^, , � �pensaaor. ' youmcs'forthwdh ;,-y-,�,P,�p�. icr�; L( �ORST.WIDENiNG ' __— . . �.�ro .. rt wi:h such prov�sio�3 0� shr.�i oc deeme�l ��.... . •eyokcd 5^:k 'RF`.1 ����.---- - , '-_�C�20��.'.�IU.tn,' !ICFNSED CONTRACTORS UECI ARA?;ON �=;e;°cc5 ''''"'`�c s,,,. I F.eref; affirm�ha�I cm Irensed under �� �:;rn..:� „ Nc:.CN�^' y provivon.n7 C opter �,�_,, ' 9 ;rommer,un w,�h Sec'�o.:7COC1 of Dwisior 3 0�•'re 3usi " """' '""'"""""°"'�'�"�''` 9 4,�i',��:.5 J1Ylg. Res• :1��:,�5�.. neu ond P•ofnssro�s Code.,ona my�icense iz m�uli force ond — � — — — efie<! �7 A p 'J^ ::���4aCi,^.a i�RE�i'TAR�CON�Ti c;;�.^..•�,r,a;.-.�;,�-.-. ' . _ > Li:CnSCn'urnbl�_'t�`Y�V�_.��C C�<�55__�L`L .':Dk:c: —_ �2�.• _2tit:nc!�iFiC'• • ' . . � m.�n p� ' —��..G�-$G�C�LW2t�St_Tlr�_ _ .........�..... v :onrrector�Q.Qc.�LLSiI•__L�Ia'e__��o1S2.V—._ (}o N,^ �a:;l� ... y�2!::iS<.=�!S• .• ���Y�.ta_I,oma �� 1.:� �/• ZG � � `�f i i �< , PG O �_I I nM1!C%C'MP°U+ItYE`I$Ef O�'11E�.Q :O. Sfr•fr '�� J � -- �;...�:.� �74887 `,..,.. C n:' ^E5:R.-T.OV O"JvORK �:� V Pl;,mb•r.qCodeard�or5ec'.,___, cfrhe ' __ �• - ' � .,. , . —'� ' V : _ . r vA. W ..t...':�:,yFt4CR;C1�E.^.s4:: .. . � 7_t.�� �� �b-�- VALIDATION ....._.,..,...y 9 8 P Coae�or'he fullowmg�enscn__,_ _ F�—�'y0'`z .-� —+�.::==•a�< --:P���--� . , 8 z . .�ale �r"_:,\"_..a.)4AIN=r�j.. •� _:hY �� I ... . .�•�_ _ '_'1 ,. .�.�H�..- �_'.� - _�.,..:'.,1. ��':�_. � C '__—_ V5 i-'�:.i.;�y:,i���:M� � Signo'ure___—_" . ,....,.........„.. . .�.. , —-1.-rih=.=�;.."a•p�•�i:3.��:.< �—i _— '—_ � OWNER-&;ILDERDEC!ARATI�L � ' :,:;4K'T':;-'^.�:,:`FN<< :�.���o,v sr.-=.ws r- �+n v�-,� !hereby nisinn ihr.�I am.exemp:irorn rnc C^.....::�,;•',,. , rr,rv ;:o4A_:• r.va*_i .�.no-�C<<. Law fcr rhe follown,g reason�Secton 7031.5 ii. �i.., , .. ... nrrc.-:n:u.,;�nE,:np�N_::,.�: — ............:... . >�ons codo: =ar. ,:os4. ..� �2 4 F i,as'owner of vw properry,or my employees w��h•ronges os r.�,o� � '� ;J •he r sole rompensotion,will do the work and iha s'ruc'ure s no' � ���•;:,•�.:or offered for sale(Secrion 7044,Bosinets � ' ,�� e� n��d•. .�,�.. : ,,Code). OWNER'S Permrt si �'-�� t L l�Jr C r'I.os owner of thc prooer;y om ex;lus�vely co•�'rr.u��a witF AUTHORIZATION TOTAL FEE �G7�S v - � ^"^�' %,i t)u IirenSed ron��ac�ors lo ronsh;�[':he Proler���59:!io^7044 .�•T:r;.:�.••� :•C i.r„4'H,;;r;.'r 7•�[i•�Rf.�na�•er.�.::e!.!:.";i;'_� :• .� Business and Profns.sion=Cnde' r_c�np^u.=n_�v':f5::��r.:x 5��n;;�.v[. �.G t�:rt=c=.:�c;�:::u v�:i.L�/"'b'b . CONS?RUCTIAN�!FND�NG AGENCY � � ���� , I hereby efCrm� �hn' 'hcre n e cons+o<.'ion :endmr oqency �!���'��hPS �"� DA'+Or �� �y� b• the Der'ormonce o* Ihe w�rk To� wiii�h �4is penrii; is �'���-���` :.�,re:,:.:=�i_�-_ � f:..r .ssued(Se�.3097.C�v.:;. � ^ � �ccrs;... . ._. : . . �' �, !ender's tiamc ...........�i...,_......_ .�.,.:..:.,...._.:.r .. Tk'- lender'zAdr.'reas ... _, .. .... ......�,>:...,...,t�..:a�.�.<...a,,,a,.,_�...:;wa..�.�..cn,x�max,c�.n..,�+w+,,.�...a.a_,�•.:ra.�<:::..:..•_�:w�::....�.:•.•.��..,:::..�.:.....,...._.�.,.........,,:,......................_....., ...,_. .' ceri�iy•na' ' nave reatl :nis nupi¢nhor nnd s�a'e �ha� �h�t �.... above�n�ornia�wn�5 ccrrer �agrc�+o:omo;y rr••i o�!Counry crdma�crfs m,t7 Sto:c i�ws.agalo�r�y Fl�mbing ona Sowcrs and here6y ou�f:on�e represen�n��ve+oi���s Cnun+y ro en•er upon'Fc a�ov:�-menaoned prope.r•y.`or�nauer!io^,puroo•sex � `'�r .�= 5=�� ������ �:. S�gner�re o,��rin�il;pi� Up�e� SEE REVERSE FOR EX�LANATGRY LANGUAGE It83PF:40R'S d10T�� ������ ,._. +,"r�?V:°a'F?R-I�JI�l,11i18 l31�.C,`.r"aR�s��'!`v �,.:.,.,:.�...�..�. . :,�,. - Af�SCCb'�IAiJ�. -YT:DA:L INSFEC.OR'SiIGN0.TURe�,� ___.'___"_.�_........-. �._..-_ ._...._"'__ "_' =:2etY'��iYS�i'if..:jd:iu^F1'(_'aii�k31Y:J1T�t.'.�•Cwi11T�?iT.::Y�:; ..-- F.ic�rFe L�v.'•'c:t;:.:�::._.v?r.�-cscazc!Sscsio�:i.3F.3. k'VI 47�5�SF`1J'cF, -'�--____'�` � ' ---'•---p ----'- �wssaxesa t.�d Prufessia�s Cadx):Any czty cr.�n:.3g. CANNECY.IODI`IONAI �- --- -�----�-------�------------- - mbic.�i regnires a pes»sit ta corutrucs,p3ee,.bmprove. �6�.mr,iuc oc woRx �,_ d:r:::::Tr":;��ir:*¢a:: :^' :::. , .... . .,.:is:u¢vsc¢, �SF.PL�C TANK.SEFP.PIf(51' '�"� ' ' ' � . . .. ... � AkD/nR D4AINFiEIv �L'SI'. !��-I.S W.!. � i IICi'ni,�:,. ••,• ": �O fb�6 r. ,,� . �..,^. J'!.. — '---'-- . . c%.n.;,• •.. �.•����.�, :%nr. �.�• ..:'8sceawed aara�asaII Ym ?be u ... p QSSM1}7 L1 �Ry:YEI.�l � . '.. . .. ... . . . • .. . ,. Ai:::'l.:M'.•'.i f:.�:.., ...f.[:::•.'�:::�5 1.lCBW9C�.tl:i�i.1N:�>�5'� ALTER.kEYniR.S'c`kEROR__'___'�-___""'�_.___....._� : �...tt".".iy1; ':./.::...':,::r.' I17Q0f Of?%3S;.F5CTt i�f'E�J@ SF.WA:3ICIS�SNLSYSiFN. __� ' __.� �;�:.•.:kf.'.'J :..: )�:njt".:°:0.:;., :r�BJ 09'$`bRE�N,°KS 8.1t¢4�Q6 �� - :.�:i —� � .�. .:he r�Jdegmd oxe�vaa¢tsoa.Any • ! - �_ _ ...._}.. ._,.. �_._— � ,-..�. .,. . . .. %.> •./it ;,: . � .,�:..� ,� ,. > '...�'� , � atr �..�...._ .........�.....H:.,..,�,.. :. _ . . . -..... �.... ' ... I 3 '' �..:. , ..;.r.:r-Yr:.: . .. � - � . ,4�.:...r. �s.. �.vvb:'... ' ��],as tke owr.cr:rf.!�z,:^gertq sa:il do 41ae work.end _ --- -- --- ' — _ . the saviceare is a::t�::r:eacea:o:aicc:eii fox sate. , . . . . /Sea 7G44.Bwsr.e:.an�rrry'ea;:osz;Code:T$^-':'ar '-'-"`_ . 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