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HomeMy WebLinkAbout1727A 1040A (10) WORKERS'COMPENSA71(3N dECLARAYiON �. ��.-. f ._.. - ..4.,�- ,: .. . _. . . , . ... � �}�Br06y o��.m,ha,�,�"�°`¢'u"`°`e o``°"'�"�°`�' APPLICATI4N FOR BUII�DING PERMIT � ,r�sure,or o certifiGate of Workers'Compensat�on Insvranca, - �+r�o cerhfied cbpy3hereuf--SSec 3H06-1�°C� '_-'- r, . .. -._-- -- ----_..- ---- t ' ° ."`. , " `:` ---= COUNTY OF LOS ANGELES BUILDINCR AND SAFETY ; �; IisY No. CompanY. _ - � � --- ------___ .:. .. � :,�� Cert�tied copy�3.1.ereby furmshed,: . .. : FpR APPIIGANT TO fftL tN '` � eu�to�n� `' ADDRESS S ��N, :. ��` �� .-: -�Cerhfied cbpy s f�led w�th the county building inspec- - gpµ,p�� . � . - .:-- -: .. . . - � �'tiCR sleparimeM. . ,,•- . .� -'- _..•,:'. .'. ADDRE55 . . , �. ' • � . . ., . � ,.... ,. i._�.': . _ _ ... : .. _._.� .. ' �. . .___..___. .. __..._._. Date.,. -- � �..AppHC0�11� :�, . - .. CI7Y • �Q ZIP . . LOChLRY. ' -. . -�'CERTtFiCAFEOF'E7ffMPiION'�R6M�WDRICERS•= �.:. .- .. _.---.�_'���x' '� NOWON�Ois � - ._'. CROSS�ST... �'... , . _..--.•_. .. . -. . '.j�.... .,.....C6MPENSAT�f9hf INSFIRAfVCE` . SIZE OF l0T - : (ihis section"nead�not be compbfed#tbe permit is fa,one . .... - ... . -......_. .__.- --_._T ,:...,_ p,��.. ' ... - ._ `-- - � � ---' - hundreddollars-_(S100jor_less.� ;_,,.:.., ... � TRAG7 � � &oCK LOiNo./ MIW�900R-^ . .._ VAGE. ... � vARCf1 . , __ -- OWNER L - G��-i ,�- _ USE ZOF� AAAP . .. _ . _ I�Sertify that in the performance of the wnr4 for which thla pp. � � ._ . } pe�mit i3 iuoed,F sfwll,npt empfpy nny peryon in any monner . . � __.. . ��qi- : a ADORE55_._ . .c� .. .. _... _____.__..�.�.._._ _. O - so:as to 6ecome-5ubjec��o the Wo omQenan . . �-� - cpp�p�pp� �. ..- . ,,,..,, . __. --_ -. �..:-.�_. . . . � . , . Dute-�. _..�..,. �p _-. ` .'� .. . - __..__._ Utt_- -'...__: _._._....-------.. ..u2.... : . ..... _ _ .. . : ... �� NQTfCE TO APPLIGWi:-.lf, •mcking fhir-- care of A��R� �. DI�TRICT c�co4rr.TYpE fIRE .PROCESSEpBY _� fxempfion, You-shoutd become subjec+-• 'aha Workers' � - Z � Compensotiart praa islons of the t.ahor fode nu mus�fwth- � - ��;� wifh compty-wirh such {azav7awns ar�.lMis parmjt�all 6e ..... . AU�aE55 ___�_y.._-.- ._ .___.----..__... YEC��` ' 1 a ..., ...- ._ Y�(� . ��- --y deemed reYok�ed,:, � .:.... ,�,.. . ::,. , . .: '. � CONiRAGfOR �Lu�.-Q/ . NO. . - STATISTICAL CtlSSIFIUk710N .. _ APf GONoO _ -_ - - [tCENSE[fCf7NTffAGTORSQEClARA1TtON. :�`. . -� .._-- .- . .._ .__ . __.:_ _ uC.-.-_--- ' CtE+55NQ. �`?-:�QWEl6UNti5 . .' - I hereby offirm itpt 1 pm�icensed undet p{ovisicns af Ctwpler 9 pppRE55 ryp (mmmenarg with Section NOQ)of Diwsian 3 of the&uiness.and _. ;. _. . � . ��. .. SEvuER AM1M . .- . - . Professions Coda.�and my�rcens�rs m folCforce a�effect CITY .. ---- --- -._ :: -- - - - � . . � CtA55 -._ . ._ . .... . � . - . .,. .. ._- �_'�� . SCi.FL. _ .__ NO OF LJO.9F_ _ _CHKK . BK.. .P�. . . . -VdC{QAT18N` [icpnteNumber .- .�.`: - -Lit."Class �""` � `�h STORIES�..'� FA/WUES ONE : �. . ....._ _ . ...: .. .,,.,,, .„ ...-,- -... . Conhactor . .` pq�e . - .- OFSC FTiON RK ' �.C�n.! �'" � S� i T�V� . . . �I am exempt under Sac. - - �� --.—. . �_ � � � � --_. �... - ._._._ _.� -_ . ...�.�- - - - p,� - - �' z1�2,7A _ .., a.s�e.c tn.��.��R ra c_t� c+ � . �_.. _. �� . _----- _.._ �__ -- = _ use oe # ...2 3 _. _ _ � _�_��"_ Ex�sTiNceioc. .+2.a _� ` -- -- . -. " ��:Siyrwfure �'. . _. :_ _... ._ .__ _...__.:° . .--- :.- nari�._ ... . .- ... ,. hL:�_-. r .- ' Fuyn�-=.. ....- . -f •1 �--7,�3} ' :_.. � � OWNER-BUIL6ER pEq,ARqTIOM1t ��PRIM Q Q 7 I . -4 hxab affirm thut I om exempi feom ihe Gontractor':liesnse . ..--.._ : .. . _ ...:_._ _ .._... [�ry� . . DAf#_ . . _.. .-- -_._ ..... ..'o � �,%..�j �'._: / Law f fhe follow�ng reazon=(Sedion 7031 5 8us�ness and . ADDaEu 7 / � H�_. . _. - - .. ._ . . . f �o��,: ..._ __ __ __ __ , __ �E _ _ a9,aa-�� _ -- �,r— — ' I, os owner pf the ro �i��' ` � . . - w es their wle mmp�ensation,wil!do 1Rha orli aed � ADDRESS . ..... - . - _ . .._ . __..._. . �.- -. ,. , . ; - t structure is not intended w offered for sole(Section . ����T�" � . _.; ..�. `�.� �� . �- __ . ,8ttsiness ond Professiom Code): -.. . -� MOVING -___. _ ._.. _. TEt.- -- - � � .� p _ ..- . - . , I,as owner of the property.um exdusively contradiag . CONTRACtOR Np� � �e.11�+"`� ���� �7 ._._ ; �- -- ith titansed cantrnciarc to'tonstruct the project(Sec-__.._.. .._. ._.. .. .__-' �__ ._.._.. . - . ADDRE55 . tion 704A,Busineas ond Professions Code). - � . DY � �� -�CONSTRUCTION LENDING AGENCY... .._.--- .._... S�.sAC�1C -raRD �HWY-. ._IOt . .._,_ . � -- - ._.. --� . . - PROP.-Llf� WIDTH` �. � I heroby affirm Nwt there ia a[onsfr�ction lending oganty for pppNT � (`�`���('�y,.�.�� ,.t ��yj lf,�fl tbe performonce ot the work for whicFr this permH�is�-�ssued ..-.. . -F.i. �-- ---..- . -.. , --,.-�:� . ... `J e ,i� (Sec.3097 Crv C.) �IOE . _ �.; - .. i.... �•• •,.��} __ ,___ __ ._._._ _.. _--..__ ._.. ;. -� - _ ` . , ,, '� � -- �___ _ _.._-- -__ . .: . e lender's Nome , + `',4�:,7$ .;. o Lendar's Address �- � �.y - �� �� \ �Y h�s_cppluarian-. ... _ _� .._ � . ._ ' P C Fee S ....__ � Pormit Fee_-' � .. 1llMA ' a a '{ J��7�J� . � 1 ceri' fhnr.l hare_fexad.t ' - and..smta...that.lhe ... hsua�ce Fee - -�nAM1A g/G-fe ; : - . ,a� above informotion is cwred.1 ogree b comply wilb CfI Coonty . Investigot�on Fee . : - .� -��-_ -� _. � .���pi,�Jr (j] m wdi�wnces ond State laws.refqting to building,cpnstruct_ion. ..._ � - i��-- �- - '. - P. J . _ ..,. . ._..___.__._. . �� - -- � iDMA Ie.m.k . _......_, �_. u on orize repreaentotives of ihis County to enix � __ �-__—_.:.___ __ �a Mhe bov entioned properry inspection purposes. - � - - - - _ � � - _ � � ' - --------- __..._ ._.T_ _ .._.,,�.-.-___-:.:,.._ ..._w_._. ..._._�.._.......- '_._. . . ,� SE6 REVfRSf FOQ E%►LANATORY IANGIlAOE _ . ___ __.5 e of Applimn . . _. _. � . �. _. .... __.__._ _ . .. . - � -' ( . . . . _ _.. ._ . . _ _. . . .�Qi _.._ . _ � _ . ._ .�_... , - � � , �,._- . „ � ' k N � . � � u.�N ,�C� ..0 . �R l� � .`� ... .CZS�'.y� O_:�,r A�+C ,_`p �'.0 .� v, N � ,,p.. � . N T' � ��: ",,.' 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