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HomeMy WebLinkAbout1410A (7) � WORKERS'C4MPENSATION DECIARATiON � 1 hereby uffirm that I fiove a cerfificate of consent ta self ,�,Pp`re�►�rion�� Fo� su«�i�G PERnniT inswe,or o ceilificate of Workers'Compenaolion tnwrnnce, - or a certified copy rhereof(Sea 380f?,lob.C.) - - � COUNTY OF l05 ANGELES BUILDING AND SAFETY PolityNP .. � Company- BUILDING O Cer�ified copy is hereby fumished. f�QR APPLICRNT TO FILL IN `,�j /(f A6DRES$ � aCertified copy is filed with the tounty building in�eo- gU1tDMIG . /� . .tion deportmenl. ADDRESS LOULItt ./7. . . .. '.._-.. ._ ..- [� �i� NE4REST Dale . ... . Applimnt � Cm' ZIP '1� t CROS55T. . . CERTIFICATE OF EXEMPTION fROM WORKERS' ���a��s• AsS�ssoR � � COMPENSATION WSURANCE SizE°F aT n�ow ON�Ot nuv soou race v,nricE� (ihis section need not be completed if the permit is for one USE ZONE- MAP �'eS- hundred dollwc(3100)or lau.) r�R � �S BIOCK t0T NO. � . N . ��' �-Y _._.. . __.. ._ " '_' . . �- TEL _ ________ . .___._ I[ertify ihat in the OWNER ( {� f NO. Y CIN�IDIilONS d performance of the work for which this _ . DISTItiCT GRIX1P TYPE FIRE PROCfSSED BY 0 .permit ts iswed,i skwll nW empby any persen in aup awnner '-�� � C T. ZONE - V ao.os ro 6ewme w6jed�o the Wonrka`re'Compte�nsation\Laws. ��� Date FS-a9- (o (�Y�' �"1 '4 ��.� on ziP ��T 6',rj l v , O �Appticom �n� sransncai anss��tcc N avr. c f. NpTICE TO AVFLICAN[:�lf,.aker maki�this Certificate-of ARCH�7ER IXt TEt... ap � V ExamptiOn,.you Should-�came w6j.ct ta..iha.1Nacke�i ENGINEER NO. !6 CLq$$Np, pWE1L.UNITS_ W . Compe�smion provisions of the Labor Coda,-yo�must fwth- AppR€ss � S�wER,�ap y witb tomply with a�ch provisions or this permit shall be T� Z deemed revoked. coyfancrat No. gK. rc, VAUDATION LICENSED G6NTRACTORS�GIARATILXJ uC. � th�hyoffirm�drotlna,J;cenaee_,u��ox+s�o„zafs.t,optec9 ,�rs�ss� �Sarn � r,o. I��^���9wilt�Secfion700D}afDivisiM�3�d#�e8t�ne�s�d - . . . . _ -...- - -- - � LIC. VALUAT[OqN � . Rofesstons Code,and my{icense is in full fwce ond effect. diY - CLqSS S ) �� � . - SO.FL NO.OF tJO.OF � CHECK . .. . -. �license Numbar� .- .. .. . ..4ic.C�-.- - - Slff STORIES FAMILIES ONE . . ... . .. .. . � ._. .._ .__._.._._ .._...__ . _. ...._. _._..__-_.__. _ . S_ .. Cpntraclor ��g DESCRIPfION OF WORK �' �� z 1 4 1,0 A �F am eaempi under Sec. � . . . y�' 1 ALtER � fINAL �?• • • • •� � DATE 'zj ';�J�"::, 8.8P.C.for this reo�pn REPAIR ❑ 1 *�3 B 7 5 - . USE OF � �ti�y oare onmr�s�ac. oF^tia ❑ � .1 . „ o��7 5� ..�.Signalurs-. . . _._-- -�---- ----.__� . APPtK�AR![_- .. . TEL. OY�NER-Ell1LDER QFCLARAIIQI�1 . - PRlNT No. � . .- 0�.2 9-8 6 � �t hxeby affirm rhar I am exempt from�he Confracsor'a iicense . . Law for ihe following reaaan(Sedion 7031.5,Businesa ond aooRE55 -Profession3 Code): . . . . . .. .. - . ._ .. . ... - - .. � +, m�ownar ot��he � BUitoiNc _. propeMy:a my�empFoyeea-with qpp�SS wugas as their aole compensotion,will de the work and - � � � tha structure ia not inrended or nffered for wte(Sedian �OC'°L�TY . 704l,8usiness�ond Professions Gode). � MOviwG -- 7et. � I,as owaer ef ihe praperty,am exd�sively cantrecfing . TRAttOR . ' .. . . . NO. ._ . .. . _ _ - � with licensed-controctors ro mnstruct the projen(Seo- A�o2�u . �tion 70M,Buaineas and Profeasions Code). _ ��� � � -" -RE(NHRED � � TOTAi SEf&4CK FROM� EXIST.� _ CONSTRIJCfION IEN�ING AGENCY - �7 gp,�K YARO� HWY p�p ��N WIDiH- ► 1 hereby affirm that them.is a construciion lending agency fw pgp� . the performance of the work for which this permit is issued p.tr ZSec.304T,Civ.C.�. Sw� v.� lender':Name . . . _�P �` � . P.C.Fee= Vermif fee yO.`J LBnder`s Add�ess � I certify thai I hwe read this applimtion and state that ihe � � � Issunnce Fee ����� above informalfon is correct.I agree fo comp�y with nll County Invesnpauon Fae g 3 � ordinances ond$mte laws relatiny to building rn�shudion, Toro�FeE a;!�� tl and hereby au+hor�zo roprasenroNves of rhis Counry ro enter � upon the obove-mentfoned pr��ctiort purpoaes. . . _ . .. . . r1p� �}� p SEF REYEBSE FOQ EXHAIMTORY UHGUAGE !� `�� Signaluro o�+1�'mM or Agent pc�e � " . .0s �,--„Q � G " d �r-�.. s�!oc^ m a...� o� � �.,_ �a o� m.. � .. ��.� .,�,H �:d�p�;N w��.0 O �s� a O ��ti��~�4�a� .�' O� S� y� 0 � 4 ^ i,.. .. .. ' ., 6 O 7S y ♦� CS y ��H M!`M�� u � ���',C,'i2'h .�y� ffi i�. �" V � i. 1`u�y ;'� ` . � � , � .; x,-n,�y N„� 9 �•#o � �. 3.v.�-e �,ti �•�'y �r . i.'o� �M � � ' O �,'� � a e�d.M}..K�� o;�;� �t �a a '�• r'"L�'o � � ,�-, m � � � i c:i ' � e >'f"�= �' �O 4.�.� �. �^� V c � b �, 7. m.,O, '�t.,, • .?L.S,r, �S "� . C . . . � ' . . 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