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HomeMy WebLinkAbout1715A 2956A (10) �,��i � . .. . ... � � � �..- . � � . . : , (� `� . icERb'COMPENSATION DECLARATIOM�� ' hl .��iereby�atfvm�ihm I bave o certifimte of eonsero�o self APPlICATION �FOR BUILDING PERMIT . NJ ,-�nsure,or p certificote of Workers'Campensatlo�Insurance, � � � ' or o cert�Red copy the�eof(Sec.3800,La6.C.) COUNTY OF l05 ANGELES BUILDING AND SAFETY �-� VolicyNo.' Company ' � 1 � Cenified copy is hereby fomished F4R APPLICANT TO FILL IN ADDRESS'�'a`�' �= ��T � ��u����Ch�';;� � .�j Cerlified copy is filed with ihe counly building inepec- BUILOING': ,� , � t'�_ a� liod deporfinenL � . /� ADDRE55 � �''..i .�'. LOCAIITY � �� + `J _L< ''�`�`! ..,. .. =� .:. \ � DafC �� ���I✓4J Applitont �`-�✓ " / }"�'�1 CITY ZIP CR0556T. r��-.. CERTIFICATE OF EXEMPTION FROM W KERS' � - " NO OF eiDGS.-, .. � n55E550R r SRE OF LOi^ ' � �' NOW ON lOT�' MAP BOOK ' .PAGE PARCEL a � COMPENSATION INSURANCE O � (Tbis setlion need noi be completed if ihe permil is for one � . . � �� ' USE ZONE MAP ('!. � V � TRACT BLOCK LOT NO �...��1 NO. hundred dollors(5100)ar less.) w (, . . .. , . iEL. � ( ',., 59EGAl (�. i r�' �' �-u � � / I certify ihal In tho performance ot ihe work far which fhis oWNER'� No.%i� CONOi7�ON5 � " w��f ermil iS iSSued,I Shall not em lo an y � f � Y OISTRICT GROUP TYAE FIRE PROCESSED BY �� p p y y person In on manner �.f } so as to become 5ubjecf lo}he Workefs'CompenSafion Law3. ADbRESS //C �� " .'1 t�h y.� CONS�(/ �014E � u �� ��� 1 Da�e � Applican� � ��� � Z�P � � $TAi1511CA1 C�ASSIFICATION APt. CONDO. O NOTICE TO APPIICANT: If, afler moking lhis Cerfificme of ARCHRECT OR iFl�. r•;' .. � . Exemplion, you ShOuld flecome subjep 10 thC Worker5 ENGINEER NO.� - QAS$NO. OWECL UNITS_� Compensation provisions of the labor Code,you must fwib- � J��:�� �� -� W A�DRE55��, �� . SEWERMAP F with tomply wi�h such provisians or this permit shall be .� ��TE�. � � deemBd�evoked. �pNTRACTOR' '� :"�. � NO. 9K, PG, VALfDAiION UCENSED CONiRACTORS DECLARATION � - , ����, �.I hereby offirm fha�I am licensed under provisions of Cbdpler 9 ADDRESS'-� : NO. VAlUAT10N t � k (rommenang wilh Secfo�N00)of pivision 9 of fhe Business ond � .� /✓ �� , LIC. �+r.-- -r �!,j���u Professions Code,ond my lirense is in foll force and effect C�iv� ' -�'"� Cut55 5 � l � •i � ','/ i..'�:+ !� SO FT� ., � NO.OF 'NO.OF CHEIX , 1 •`'!.•2�, License Number �� Lic.Class � 5¢E�-.•���✓ ' StOR�ES ^ fAMtUES � ONE � ��� r / .s /;i �.-,J I`�?�L�:. J� f'L� l " j�:+i�i � j�/�G/�}`'j � DES�RI7TIONOFWOkK N� �� � -Contracror � r � Dote �� �M � � . �I om exempl under Sec. �� - -��! - AbD � .;���2 Z`e.a L. 8.8P.C.for this reason . ALTER ❑ DATEL ��:i,C.� ,�D � . - REPAIR � Dpfe: . USE OF DEMOL FINAL , EXISTING BLDG. � � ❑ BY Signature �� - ' APRICJNT.. tEL � . , OWNfR-9UftDERDECLARATION � ��M�� NO.:- -'•J I bereby offirm thoi t pm exempl trom Ihe Canhactor's Litense . '- , . � � law for the following reoson(Section 7031.5,8usiness ond ADDRE55' � ' - � P�afasaiom Code): . � pkE N ' ,r'[���:x.b�4 ❑ . . . . BUIt�tNG . . . � :,1 ,,;, , i,�,os owner of fhe,properry, or my employees with � A�DRE55 � wages as thnir snln compencolion,will do the worY.er.d . . it�;'.!.,•.`.l, the sfructure is not intended or offered(or sole(Secfian � ����TM ' � 1 . . . . � " :,:�n 7044,Bvsiness and Professions Code). MOVING� � . . TEL. � ,�, :.�,. �'(� � I,os owner of�he propetly,am exdusively contracting C MRACTOR ��N0. ' ''"r_..-. ___ . witb licertsed mntmctors lo consirud the pro�ecl(Sec- ' q00RE55. � � `���N�.�,`•t�v�. tion 7044,Business and Professlons Code�. - -' � �•���• - � RE4uiRED TOTAL SEIBAIX FROM EX15i. . � . i.�Y„1,�,;�B.J. � -CONSTRUCifON IfNDING AGENCY - -sET BnCK YARD� .HWY FROP.lIN W�D7H � I hcrehy afRrm that there is a cons�ruciion lending agenty for , tQONi:� `.. . � . � � the performance of Iha work for whith this permit is issued �. a.L � ' �Set.3097,Civ.C.). � ' $IDE , . - � P.l. . . . . . tender's Name � \ � Lender's Address � ' � . P•G Fee f `" n���.�-'�.7 Permie Fee�% �`��1�(�._ � . I certify iha�1 have reod ihis applicmion and s�ma fbot the ' �' � � Issuon<e vee t U��.�:� ' obove 7nformaffon is mrrect.I agree to�comply wilh all Counry . Invesr;garion Fea � �� ordinances ond Stare lows relating to huilding consvucfian. � � � �+ '-'.���7 C.�j '� and hereby awhwize represeMofives ai this County�o enter imol Fee�.:,v + vpom I/hep b/ove-men�o,nG�''d-properry for inspeclion,Purpos85. . /J ; f��.,!� � .,i � ;� ,1 a �� '`t'" '!�,ls� f J ~�� %/�✓/r�7� . � SEE RFYERSE FOR E%�UNRiOAY L+�NGU�Gf � � ' , ✓ Slgnor�re of,AppL'rom or Agenr pare ' � � � � , �� � . o� � � � . . . � a;7'. , . . . ' . . " .. ' 1 � . . ' _i- - " ' �t , - � , *. ". `��.1 •�1 , '.` ,., �t � . . � . ..'� � � � . . � ., 4 �' , �' ' . � ; ' � � � � �.� � .. �I � � , � '. i . � � . . ' , � , � . r . . . . . . . 1 � � . �, . - . . �� . � ; � �.. ' . . . . r � , ' . . . . - . ' ' � , ,� ' ''.•.. -- ` . . � _ ,� , . �� ��.,l �� � �. '� , .. . . � . �� ��, � . � . ' ' , ��, .. � i �� ��� � �� �� �:� ��� . ' �. .• . , ' 1 ' �_ t� ! 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