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HomeMy WebLinkAbout1584A 1585A /' �ORKERS'COMPENSATION DECIARATION � � � � � U a ffirm that I have a certifimte of consem to self � e p�L1CAT'OIV FO� �UfLDIN� PE�MIT �nsur� �r a tertificote of Workers'Compensation Insurance, �-� _ or y�cerlified copy�thereof��ec.3800.Lab.C.) - _ � Po�_� /�[i �fL ,� COUNTY OF lOS ANGELES BUILDING AND SAFETY yN2Y �GO�Company/�JZ) �/A3DEfNL�T. - � Cerfified copy is bereby furnished. FQR APPUCANT TQ FILL IN BUILDING ao�rsEss � .Certified copy is filed with tha county buiiding inspec- BUILDING. � . - tion deporfineM. ADDRE55 LDdU�flG GGi�Ss �pCq��TY �afe�'—.�—£rG Applicont A."h•o-�...: c�rv DI�J'/y/B�vD Q�/L na cR�assssr. �RTIFICATE OF€XEMPTION FROM WORKERS' SIZE�tOT G�X��� t�W ON LDT � MAP BOOK PAGE PARCE[ - COMPENSATION INSURANCE . . (This sec�ion need not be compleTed if fhe permit is for one - � USE ZONE MAP - � huadr�doltars(SIOD)w I�s.� Taacr ,5S � siocK iar rio./� . _.. _ Np, . .. . . . . TEL. . - - SPECIAL 1 cenify tFiW in the perfwmwnce of she work fur which-ihis OWNER- 6 p�p, �Q aZ�L - CONDRIONS _ _ � permit is isstied,(ahatt not empioy any person in any manner DiSTRICT GROUI� TVVE �F�RE PROCESSEO Bv (5 �o 0810 becOmB au6jec11n the Workers'CompensnNon 1.p�ws. ��� CONSTr;+ 7 � U y ��� � Da1e .. . � App iicCM � . . .. CIiY � ZIP STAtI5TIG4l CL455tF ION - � APT. CONDO. O tJOTICE TO APPLICANT:�R, nftar mnking�this Cxtificuie of ����� ' T� . .... .. . .. . V �Ezemptio�, you should become sub}ect fa.the��Vlorkers' C1A55 NO. DWF1L 11NIT5� Wa Compensatiortpravis'uns of fhe Lot�nr Coda,ynu musl forlh- �._. �DDRE55 -___----- ---------/F----------- --.__SEweR-Atnr . ..._._ . .__. _ _ _.._.. ..- .�n with camply with such provtsions or th�s perm4 shatt be �� �� 2 deemed revoked. ... -- . . q3'7S7I VALlDATION w corarwacroR . ? __ _ eic. a�. uceruEo Cotarwicroas oEciawinav C uc 3�¢O�2. I hereby affirm thak I am IicerEsed uoder prayisfam of Chayter 9 nooREss p � A/ N6. YAIUATfON r se - (commendng with Section 7000)of Divisioh 3 of ihe @usioasx and ... . LIG - Pcofassions Co�k,u�my licanse�.b irt 4vU fmceand eHect. CITY U$h1 CL4S5 t���d� � -. . icense Number 'i�40Lt 2 uc.Gns�C L/f Ci� SQEhT. S OR� �a�,ni�L� on� . � COnho[tor�, W.�A^,L[t rt� Data.. .�`�.—�L OESCRIPTION OF WORK N�ry ❑ S . . �1 om exempt undw Sec. /IJL1 %Q G' !f� ��_ iJ � Al1ER � fINAt n.w,��: . B.BP.C.for fhia reason � R��R � ..DATE -��'V !.,r' �� Jr$,LI.A oare: e��einc. o� ❑ g�' �'�� #... .2 3 _ y (� /� � ��ru•�O�E�M BUIL��/��--. ,aw«CaM 7EL. . -- ���T� � PRINT NO._._ _ � I+�L S.O O 1 hm aKirm thW i�am ax #rom ti�s ConNactors license - - �1C.-D V � low for the folfowing reawn(SMion 7IX31.5,Businau ond A�Eu - �����. • ' •L�C C c.=i Profeuio�u Code): _ � - � �I, of owner of iha property, or my employees with ���q�p�� � - �+��G�&6 woqes as their sole compensoNon,will do the work and � fhe snudure is rrot intended or offered tor sale(Section ��b`��T`" L� �'5� 704t.Business and Wofessions Code).. mOvit� iEL . � I,.as owner Qf rhe proper�y._am exclysively con�raciing . .�T� NO. �'�•' • • �� with licensed conhactora to conshuct the project(Seo- ADDRE55 � • •�'J Q 7� tion 7W4.Business and Profeuiona Code). . . . _ ._.. __. -__._.. RE(X11RFD TOTALSETBACKFROM E%IST. CONSTRUCTION LENUING AGENCY� � � �gq� �Y/Ut0 HWv pRpp,UN Wi�iH � • ° °�J Ct`]rj c*i i hereby affirm ihat ihere is a construcfion Iending agency for pgpM the parfwmance of the work for which this permit is issued r.�. D 9:0 2—8 6 is�.�,r,,.c.�. s,o� _ .... _._ _. .' . . P.L ' . Lander'a Name . /�(� ._. $ P.t.Fee f t�l.! Vermit Fee � �@nt�9f�S�d19S5 � �cenify�that!hove read this application and srore that�tha Iuuance Fee 1 � above informmion is correc�.1 agree ro comply with o�l County ��„��;qanon Fee ordinontea ond S M lawa relafing b buNding wnshuction, Toml Pee iY ond heraby aut rize rspresentntivw ot thi:Couniy to errter � � upon the abo •mentioned prop ms �on p.� . o � SEE REVEYSE FOR EX►tAMATORY Ui1GUAGi ' - ip�mlure oE Applicant«Agent�r � pofe � . . .�t Q'v� ���,^.�t� � �.o���M� LF�y, ,o �ti,Z�'� oN.�� �M__� « i, � �•.w�.. h.,, �o ;*,,'�. o ,, : ,.. i ^�„'"t' v �.v1 b b #� ` �i�' ; .: y « ,� .� „ ' ' ..y`, �.c �o�i my � o,�;,.�o A�.� �� m��::� u a, . c y� � • o-- o �:°i ,i.„�`A,cn o,"� �. ?i tii o � � y"� � o .. o u � � , � �i w� �.�.cl, .� ��o '�O""�S .Q o y�4'":w � -L i�., � �•—.'x °� ..-U ' ' - . � '� . 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