HomeMy WebLinkAbout1046A 1152A , --- WORKERS'COMPENSAT(ON DECtARA7iON � ' �. � � - ; I hereby affirm tha�I hove o cert"rficate of consent to se�f , : _ �^^�'���I�� ` .� �. . , .� ' ... � � . insure,or a cerufica�e oi Workers'Campensation Insuronce, rr FOR �BUILDING PER I 0�a cer�ified capy thereoP(Sec.3900,�ab.C.) � - � - �iT� � ' P❑olicy No. Company COUNTY OF LOS ANGElE$ Ce�tified copy is hereby furnished. � , � �BUILDING AND;SAFETY ' � Ceroif:ed cc s filed wi�h the wunt huildin ins ea '� > FOR APPLICANT TO FILL W . BUItD�NG: �� . i P7' Y 4 P BUIIDING' 7 � ADDRESS+f�'„`�'� �„1::�.�„� . . , � fiondepartment. aD�Re55 - ��:r .! E��,:-(a/d .. . . � � � -7' IOCAUiY //✓J.:S r/ /,f... Da7e Applicont ; CftY/f i���.�� - . � If� !�J CROSSST �.,U/ .�:ir' �t"� .. � CERTIFICATE OF EXEI'dPiION FROM WORKERS' - � � Z�P r � �>�l..,/ � � I SIZE OF l0T NO.OF BLDGS. y � , COMPENSATION IWSURANCE � NOWONLOi f/. , P'��OR � � � (Thit section need not be compfeted if the-permif is for one I �� �P B�K � ' � . PAGE � TRACT � 'PARCEI�. a . hundred ooltars(5100)or tess.) �.� � - eiocK� ioT No. use zoN[ nv,p .��,_ u OWNER ��,f�'I�� . .TEI:-. � , NO. I certify thot in the performance of t6e'work for whith ihis � �''�i 7�, '-'.�C N�.r,,..��;- .�� L' ',,,,. SPE6q1 , W �, � permit{s issued,l shall not employ any pe son in any mann2t - � � CON�ITiONS� - = ' � ` ' Eo as lo become su jecl to 1h0 Wor e � ompe�safion Ldws. � A�DRESS � " � DISTRiCi .GROUP {ypE F - �t� f. � . CONSi. � . ZONE ��ESSED BY } ��/�,� �� � . . ' . Oa1e�Applita���� !`';.� � i CITv iY r�, r� �i l/�� ZIF /n ' '�-i . � , IV07I4E TO AP,I:AP�T: If, chcr mq,�n th�s Ce�tifi�ale Of � ARCHITEQrAR� . . STATIS11�pLClASSlfl�qTlOry � � K Exempfion, you shOV�d be[D•^.�c Subi[t to the Worlce�s' ENGINEER>'a.;�//;�.�-c:�.r �:�.;�� N� �� ; ' � ..4F7.�'CONop,�^ � ' Compensation provisioni af the Labor Code,you musl forfh- I � ��„ C1A55 NO. � DWELL.UNITS�,� � . d � with comply with such provisions or th�s permit shall be AODaeSS _ �r�, �� : deomedrevoked. � � - .�„ . SEWERMAp , � .• '�, GOMRAROA I'.Fl/l�iCr',��./f-�J/J� IE! � .J . .. ' !- . UCENSEfl CCtJTR�CTORS�ECLARATION � Na'�' ���' eK. PG. � - VAUDATION I here5y af(irm 1hc�f am licen ed�ndzr provisionz a!Ch6p�er 9 ADDRf55�i �'j . !l�� � liC.-�� � � . (commencing wBh S�znen 70CYJ)^f Divisron 3 of the Buslneu and � NO L•� VAlUA710N � � Professions Code,ond my I cense k in fuU force and effett. Ciiv��r����`;-�/� .��'�'�.1 _ LiC. - :'?'J . � � � 'i(.' : •): 5�.� NO.OF aass. .-: a �T�L',_ T�:G"L F•. NO.'OF Ucense Number�� lic.Closs � SiZE-� • STORIES � fqM41E5 pN« . , , f- !,c:i, � ' :I. . .. /'.:, ''''S� DESCRIPTION Of WORK�(, Confro.�or` � Date /%,.'/✓'-' NEW � s -.. ��� �.,�:G� . � �I am exempt under Sec. �<��� i�/ -��ri-'�/ /r. .r:�v.�..',�7/' noD � . . . . . � : . •. ,- '.����:��r i, B.&P.C.for lhis reason /� � , AUER � FINAI . . . . � L t �:'�e. '( � . ' Q DATE. ' . . ��.i .. Dme: � USE Of . REt'AIR � � . . � EXISTINGBIDG..�/C l�/'_!.-{✓�..r.,:� pEMOf � FINAL . . . � . � Signature APR�CANT. ��r TE[. BY � �� � 04VNER-BUIIDER DECtARATION rRiNi II'C�'dl � ((G r"�'r � � � �� I hereby offirm thm 1 am exempl irom the Controtror's License � ��-ry �� NO.:�� ��j� : , . , � low f�r ihe(ollowing reoson(Section 7031,5,Business and AOORESS��'%Y� �',%�.�,�!����,i ��� �j j,,�,�, S � . _ Professions Cade): � PkE N - ' � � ' QBUILDING � . . _ . , ' . . . . , l, as owner of�he property, or my employees with qD�RE55 wages as their sole tampensation,will do the work and � ' � � �� � � � � �he stroctura is nat intended or offered for sole(Section ��ei7r . . ' . �' � �. 704A,Business Gnd Professions Code). . MOVING � � . � � � - � � ' .� . '"•�'���,5�K�i � � CDNiRACfOR TEI. - . . . .. , , � I,os owner of ihe propeny,am exclusively eoMroc�ing NO. �}:��s�"�w w�a�; wilh licensed comrac!crs to consrruct�ha project(Sec- qooee55 � ' � � � - � ��on 70d4,Bvsiness ond Professions Code). .� , . � � • h` I`_ REQUIRED � � ' � CON5T2UCT�ON L:NDING AGENCY SEi BA�K yqpp Nyry TOTA�5p7gACK FROM exisr. � � � � 1 hereby affirm Ihor the.e is o construction lendmg agency for tRONI� PROP.LIN W�DTH ,. � � ' • �H t /�y E., the performance of the work fo�wh�ch this perm�f is issued e,i_ � . . � ' - � • � (Set.3097,Civ.C.). . . SIDE � , � . .. j.� � a.i. G. /r�,-��. Lendei s Name '. � -� � � Lender's Addres;_ � .G Fa S ' '�� permn Fee �/ ' � � � � �.� - �—_�`__. . � .. , f certify.iha�I hc{�e read this apptica�ion and stare�hai�he � � Iswance F�e �'�r' � a6ove miormotipfi is correcL I ogree fo comply with all CouMy Mvesfipe�ion fee � � � � � � � � .,g ordinonces ond�5�ate lows reiaring to building construMion, • - � � , ,, � . - �� C dnd hereby oo�norize represemptives oF Ihis Counly lo eMer - ioiol fea i„�' � � ' - � � . � m;t ��up6nlbe abode-rtieMi ned prope�ty far inspettion porposes. ` ' � - � / ,� � �7�..' � /4���_� � '`��//4 ".r��'I SEE REVERSf FbN E%itANAtO1tY LANGUAGf . �� � ,� . ' .. , � Signat�re of Applicanl or Agen� Dole . . . . .. - � � . , � . . ( . . . . ' . . � . .. . . . � .. ' . � . 0i �. . 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