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HomeMy WebLinkAbout1250A (6) �ERS'COMPENSATION DECLARATION �- � �� � ' � .,. ��"� � � -' -� -- " � • � - -�� - � � - • � � � ��!;�� �tha�I heve a certifica�e oF�o�=e�„o,e�F - -APPLICATION FQ� BUILDING PERMIT � ��sore, _..fico�e of Workers'Compensotion Insuronce, b�o cernfied copy ihe.eai(Sec.3800,lab.C.) COUNTY OP LOS ANGELES � BUILDING AND SAFETY Pol'cy No. Compony � <e�titied copy is hereby tumished. FOR APPUCANT TO FILL IN BIIRDING ' IS /� • - ADDRFSS (� � Cerlified copy is liled wiih ihe couniy buitd�ng inspec- BUiI�iNG ) Mr p�r j� � . .. d�. ��D�deparlmeN. , . , . ADDRESS 17��///G/JJ/ir' pete - APPticanl . � � � .. ' GTV u ZIP IOCALITY � • CERTIFICATE OF EXEMPTION FROM WORKERS', _� . . NO.OF BtDGS. NEARESi /� �� COMPENSATtON iN$URANCE SIZF OF lp� � � - --�NOW ON l07 � CRD55 ST. Vi.l�r C+ � (This sed�on need no�be compleled if the permif is fo�one TRACY• eIOCK � lOt NO. Q AUE550R � . hondred dollars(f1Q0)or less.) - �� 1, ey 1/ M/+D BOOK � PAGE PARCEt S � AYQSI7I NO. aUU J US ONE MAP I c0�tify Ihat in Ihe periormon o1�he wark for which ihis � ��ER ��/ Ap, C��'��j3 �' - permit is issued,I Shpll�ol em y dny person in ony manner SPECIAI n' so os�o become subjett to th rkeri Compensotion laws. ADDRE55 � � ~ �V dC) C0401t10N5 V �Date�1���4PPlicant ' CITY N Z17. �7�7�p . . . . . . O ARCHITECT DR �) TEt. NOiICE TO APPLICANL�if, Ihis Ccrlifimfe of ENGWEER '��QG�ry� O. DISTRICi GROUP ryPE � FIRE PROCESSEDBY F-r�. Exemp�ion, you zhoold be m o the Wo�kers' . . . y�� CONST. - ZONF i� Compenso�ion provisiom of the lobar Code,you must ionh- qooze55 '�' 1 W wilh tompiy with such provisions or Ihis permil sholl be �n J •�h N� deemed revoked. � ' � —� TE�• -�� STATIS�ICAI C(ASS�FJ�.4TION �A➢T. ONDO. Z CONTRACTOR - NO. IICENSED CONTRACi0R5 DECIARATION� � ���, Qn55 NO._��pWEll,UNITS� 1 hereby affirm�hat I am licensed under provisians of Chop�er 9 ADDRE55 9 - NO. � � � (commencing wirh Seclion 7D00)of Division 3 0(ihe Business ond ��� SEWER MAP , Profezslons Code;ond my license is in full torca and eHecL � �Itt '� � � � Ctn55 � �� VALIDATION ' $�.FT. NO.OF NO.OF CNECK BK. " PG. - - � � Litense Number Lia Class � S12E - STORIES � FAMILiES ONE� OESCRi7TION OF WORK vAIUATnION N� Q , Contractor Oole ADD � s �v4�� , �I am ezempf under SeC. A�TER 0.8P.C.1or�his reoson �N� �t� w REPAIR � s .. Qa��_ - USE OF � � DEMOI Ex15TING BLDG. ❑ Signamre .� . nPvuCANi . . - . -. . . . TEi. ._.. . FINAL �/ OWNER•BUILDFR�FCLARATION PRIN7 NO. DATE� � I hereby affirrrr tho�I am ezempl!rom the Comracbr's License � � � � - ��� � ��- - . �� � �_— � :'� G 5,�P law for ihe following reason(Setl�on 7031.5,Bosinesa and ADD4ES5 F� . . Pro/essions Code�: , ._ _ _.. . PRE ENT .... . . . A� �• • • • • � (Q BWL�ING � � � ���� !, a:owne� of the property, or my employees wi�h qDDRESS � • �2 5 J Q -� wages os their sole compensoiion,will do the work and � - . . . . . . . . - � . the svuctwe iz nol inrended or of(e�ed for sale(Secfion lOC4liTV • • 0 2 J.G�� 70l4,Business ond Pro/essions Code). . MOVING. TFI. . � � I,vs owner of Ihe prope�ty,am ezclusively controtting CONTRAC70R � NO. � � D a 3 Q—8�5 . wifh licensed coniractors lo construcl 7ha projecl($eo- pDDRE55 � ��� ���� � - ' �� -- � - � �� � ��on 7044,Business ond Professiom Code�. � � .� CONSTRUCTION LENOING AGENCY bE�BnCK YARD tiwY 10iAPROP.UNE WiDTH � � � ' I here6y affirm that there is a censtroction lending ogency for fROnt - tha performante of the work For which this permil ie issued P.L. - (Sec.3097,Civ.C.�. SIDE � P.L, � lender's Nome - � � � � � � � IS�1 LDMA Ref.M �- � . Lender's Address � � � - . P.0 Fee S Permii Fee _ ' . 1 certify ihm I have read this opplicolion ond slate Ihot Ihe Isauance Fee ��•, IDMn P/C N abova informotion ii mrrecl.I agree lo tomply wilh all County � invesngo�ion Fee .�'., � . �� - or o�ces ancJ State lows reloHng to boilding Construclion, taol Fee �r� IDALq perm.X � � a hereby ouihorize repreeenmtives of this County to enter � � - � � � u on�he abova-meNianed prope�ry for inspeUlon purpases. � � - � � p�� .. . .. .. . . .. .. .. . _ . . . .. _ ���5.'J✓h i\! SEF RFVE�SE FOR E%7IANA70�V IAMGVAGE Signorura oF Applicanr or Agenl F�f—f7 �T nz o o � " �, o �,� 1 . a. �,� ���.. __n. ,�.... .,.- .r- :, --T- ,- - - o 0 .. 7 n O O O �a + ..r . ', R .. J � R o ., c T 7- � � C' : C C , x 'p� � r ] y .O ' .¢. �� � L I � ' p � ^ � m �O K N G n � .y . 7 � !� C i �� 0..� , 1.� 7 r � I z �:< � � � � O � � ( C: , � 0 0 3 A ° O c � P' � o ic p�;: fl� �° �� � r , v� ' � • ] �. Q � < < ri � � .. 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