HomeMy WebLinkAbout1021A J . . .... . .. . WORKERS'COMPENSATION DECLARATION - � � � �nsurebor�ce�fkore ot Wo kea��Com'pensoton�nwron a" � /�PPLICATION--�-FUR BUIlQ1NG PER�l11T oro cereif�ed copy ehereof�Sec.3800,tcb.C.i COUNTY OF LOS ANGELES BUtLDING AN�SAFETY Polity No. . Comppny • � Ceni4ied copy is hereby furnished. FOR APPLICANT TO fILL 1N ewto�r� 2� � ADDRESS � Certi4ied copy is filed with the cooMy boilding insper BUI�DING �` / ss lion deporiment � AQORESS lY• L.•d . oa�a nmeu�o�� cm A.�z�P / ioouin - CERTIFICATE OF EXEMPTION FROM WORKERS'� �� - ���8��� NEAREST �COMPENSATION INSURANCE 9ZE OF lOT rIOW Oni t0T Cft055 ST. (Thia aecfion need.nui ba-comPfeted.if the pefmit ia fw-one . TRAC4 � �-- &OCK � �tQ7 NO. ....--� AMP BOOK =. . . � VAGE PARCEt hundred dolims(SI00)or leu.l - �L. OWNER ryp. USE ZONE �- Z.���7 I cartify that" � e performonce ot the wark fur which this /,��J �. permi!is i ed.I il not employ ony�arzon in eny manner , A�� +� /�/6 " �� Cp�IT10NS �� ao�as to 6 m 6ject to the Workers Compenwtbn laws. V �� - - ._ �r�&^F� arv �3 nr (?f a Pate ' �Appltcnnt ARCHITECf OR 7E�. M5ERICf GROUP NPE � FIRE SSED BY O NOT APPLICAtdT:�If,aher maki�g�thia Cenificate of E��R t.ip. -- -.- - � 26NE� . . f— Eaempfion,�yoo shnutd-beceme subject to the Workers �. .�- . .�� � - -- V Gompanwtion Rvovisions o#.the lahpc Coda.You.mvst fceth' ppp�� � - � I � .-J �'� . . W with.comply wlth suth provroiorts cr�th'rs permH--shCl{-be � TEL. STATISTICAI CtASSIFIC0.TION � � �T. . . . Z deemed roroked. . . - .. _ .... � CIXJ7RACfOR . NO. LICENSED CONTRACTORS DECIARATION .. tIC. 40.55 NO- �w�t�.UNITS "" t hareby aff'rcm ihat t am licensed under�pror�aiona of�Chupter 9 ADDRE " NO. SEWER MAP ..._.. .. . . (com�rcing With SecYon 7000)04 Dtviaon 3 ot rhe 8usiness and ---. .__. __. ._ . .. . tIG. _..- .:.. - . .. � - �- � Profeufons Code,and my lieee�se i:xn fuf4 fwee oerd effeef. � .. dTY� . . _.-CtA55 - _. -&t. PG. -�. --- -.- . ._YAIiDATIFiFF --� . . , . -. .� ... . -: 5�.fT. � NO.QF .. NO.OF CMECK ticensa Numbir tic.t4o7i � �� STORIES PAMIl1ES � � .- -. --_-. . -- . ,:._: _ ._.. , - YJLLURFlON � RIPt10NOFW(3RK��. A Nra dN" . �� � _-_—.� .. . ,� s �, � - z102.1R Conrrodor oaro Ao o_E /NO � �1 om sxempi undar Sat. _.. .:� . . � - ALTER �� .. . _ � � �• • �• � � . JN oNc- ,�f ad f 8.8P.G for Thi1 ronwo � . ^ REvaR _ .. . ' � ��C.yr,� . .._�Doteo . USEOF __. ._.._ .. ... . ��._ .__. ._. - ��- � � E7(tSTING BIDG. -�- . . . - _._.. .t$iqllOfU[B -... . : . .. _ F'PPLIGHT _.. TEL:. _ __._. . �'"�-�) 'i .:_ _. •a�♦w�:`J C c�_-• _. - DAE Z7 �i U Q�,� G—�o OWNER-6UItDER DECL4RATION PaiNT �� ✓ � , I hareby affirm that I am exempt t[om the Contrpcto['s License qppaEu � �� . - _ . - NKu--_ .- -. law for Ihe followinq rnawn(S�ctio�7031.5,Buainao and .. Q , .. Wofesaiom Gode): -� - --:�._ , _. __...�__ ...__ ... Y � euaoin� / 1,m ownor of the property, or my employees wilh ADDRE55 ��, � ,�/O�f� -wapas aslhe�r sole compenwtion,wiil do rF�s workcw+d ��� � (�� � �he strecture is nof interded or offered for sole t5ecfion TEL � - 7044,Busineu and Profeasio�s Code)• . - � �V��-- . .. . ❑ MRACfOR �. I;pt owner of the property,om exdusively confracting a�G�o -wirh licensed coniractors to COnShuct�he p/D�e[I{$ec- ADDRESS tion 7Qd�,Business arid Prnfessions Code�. UIRED Tq7Al SEfBA K � � CONSTRUCTIQN LENDkNG AGEMCY �SETencK �Y� --�� -�----PROP.ZINE-�"�'�- �wroiFi - ����n' � � / ^ I hereby offirm that there is o conslru<fion lending ogency for .pqpM7 �������_L ;/'�(r ,�.t�j„ Ihe perfama+cs of fie work for which this permit is iuued a.l. �/ - � - (� _ (Sec.3097.Civ.C.). SIDF P.t. l,endar's Name .� tpAAp,Rof.N $ � .,. � .. R.C.Fa�S Permir he _ � , Lender's Addreu . . � {�arrify IFwt I have read ibia appl{totiOn tlnd atote ihal 1hs hsuanca Fee /O� LDMA P/C N � above infamWion i�tortect I ngree to comply with oU County Inve�tiqalbo Fea ` 8 ordtnanc�s and-Stote laws rolating to buildin9 conitnteNo�, TWoI Fe�.. ����V IDMA�Pxm.M R a�d henby aut � representnti�ea of this County to onter . � upon the abo - .Ian�d WopKh fw inapsction pwposea. ^ �—�� see�ev�roa��rortr uNou� - si oe,+aWicon+«Aw�� ooh . � r > . . ... `. .r... . r ^ � y`� V y y i. . � ''C .�.,"� 01 .� ' . . .Y -p�V' Tl p Ci Q �.'- tf�i v y �, „ . -p . . � 4'K ' G ^ �„ `� `n.".�'�µ -i C�.�.C ,i � `� �C .3 D L? � �a S G 1• o�. � , O u � i. ` � t1. - . t^."', 'Z y �p � u y y�. p�t") '_�= � � '�'� ^� �" a.'c v`�. ^ � .� �„�R..y. > O � �y � �- . a o " � y `� ^ " .��^' :�,m o �,_h.'t;;; � r � � � y m � r'` 7� � r. �v � ' y� .. p 3��. x a " .. > p-`� ,�q y = �m- . O U Z43 �, y i y���.. 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