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HomeMy WebLinkAbout1180A 1181A iWORKERS'COMPENSATION DECIARATIpN , `'hereby,cffirm tha�1 hove a cenificate of conunl to telf qpp��CAT10iV FOR BUILDING PERMIT insure,or o cer�ifitote of Woikers'Compensation Insurance, I ar o cenified copy thereof(S�c.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING ANp SAFETY �. policyNo. Compony BU��D7NG ��. � Cen'rf�ed copy�s hereby fm�+shed. FOR APPLICANT TO FILL IN AppqEu 2/(77 /��7�i��n � Cer�ified copy ia filad with iha county building inspee- owiDtNG /►���+3 ����� -71/A�O�f, g�.�• fion depar�menf. A�DRE55 L. p S✓ Oale Applicont CITY •J/��O�O 4Xfh� iIP LOGtITY CERTIfICATE OF EXEMPTION PROM WORKERS' �'�et�s� � �R�S$7. �1� CA-N`1'� ' COMPENSATIOtJ INSURANCE SiZF OF l0T . NOMi Onl iAT �This seCtion nead nol be completed if fhe permit is fior one ASSESSOR hundred do�lars(E10p)or 1e65.) TRA�T BtOCK LOT NO. MAP BOOK PAGE PARCFI �j}� �g TEt.A 4_Z� USF ZONE �P / � 2 1 certify thol in the performance af the wark for which thia OWNER rr'rin��NVc�� NO.'7'7 No. .�'=.,33 � psrmit is issued,1 sholl nol emp�oy any person in any monner �,�j SPEC�AL t w as to become subjacf ro Ihe Warken'Compeowtion laws. AooRE55�7U'�� m���E'� SU�r�f� C P� CONDiTIOnlS U; cRr�ieY/NE ziv q't/� d• u r-v� � Dafe AppllcoN ARCHITER OR TE�� / DISTRICf GROUV TYPF fIRE OCE55 D 8Y O NOTICE TO APPUCANT: !f, ofter making this Certifimro of EMGINEER Qw��� �.�7g�2� n - ro�� z� V EKempiion, you ahould bemma aub�ed to Ihe Workers' KaL `f w Compenwlion pravisions af the labor Gode,yau muee forth- ApDRESS a J ���� '�- Wilh COmp�y with su[h p10`/iSlons Or /hi5 permit ahall ba TEt.yyiy/Jn.�n STATISTICAL C1A551FICATION �T� ��N�� Z deemad re�oked. �pPIfRA[TpR -Q /✓� NO!'p/'TG�/�R•r � � LICENSED CONTRACTORS DECIARAiION IIC. ���'�""""'��� I hereby aifirm thw I om licensad undar provisions of Chap�er 9 .aD�RESS NO. ��R�p (rommencirg wilh Section 7000)of Division 3 of tha Busineu ond LiC. Profeasions Code,and my iicense is in fuil forca ond effect. oiv M55 eK � �� VAUDATION � SCi.fT. �^ HO.OF NO.OF CHECK Litense Number Lia Clos• S12E �J STORIES 2 PAMIL�ES �E . ❑ VALUATION � OESCRIPTION OF WORK Ll�i¢u+ NEW Conrracror Date s ��� , �I om exempt under Sec. � � �hp � �1 1 �O A � #�'. � • �2.z. B.BP.C.for�his reason T� E .G�L�M REPAIR L l uo�e: ezssrwc awc. [��F/C.E$ oema ❑ I • •3 2 9 4 $i naNre APPLICANT-�y 7EL. ..�A PINAI • e a�j 2,�'��� 9 PRIM1 rN�'FIA��� N0.4/'r�?�d , . OWNER-BUILDER DECtARATiON DATE I hereby offirm that I am exempt from�he Contracror's License A��E��?�j/�2�f��{.L(, $/f/JF/Oy,�,1�/� flNAI'/� �+ �e'� 4—�7 Law fo��he followirg reoaon(Sectio�7031.5,BusineEs and ProFessiOns COde�[ FCESENT dY V v =�,1 1 &1 A ❑ BURD�NG I,as owner of the p�operly, o� my amployees wilh �. ApDRE55 woges as Iheir sole compensation,will do ihe work vnd � �� � � � �} ' 1he siructure is not intended or offered fw aale�Section LOCAl1TY J6t4,Busina3s ond 9rofessiona Code}. �vANNG TEI. � • •4 4.2 5 � I,oa owner of Ihe propeKy,am exclusively[onNacling CONTRACTOR �� � � with licensed tontroctore 7o construct fhe ptoject(5ec•' •4 9.2 5 c=.� AODItE55 tion 7041,Business and Rofesaiens Code). I Q� �l�8 7 WNSTRUCfiON LEND�NG AGENCY SFT�BAOC YARD HWY TOTAL�uNE WIDTH I hareby aff'�rm thef Ihere is o construction lending agency for FRON7 Ihe perfumance of the work fa which thia permit is iss�ed v.l. . (sec.3W7,civ.c.J. sioE - , ;'�r, ;:,,� v.�. � Lender's Name ���E �{ p p- IpMA Ref.N $ �b�� P.C.Fse S �� ! Pxm�t Fae �8'��7 � Lender's Address � � I certify thoi 1 have reod thie opplicarion and swro that the iwwncs Fes � WAM P/G M o6ove information is corcect.I ogroe ta comply wNh all Couny Invsst{goNon Fae $ o dinoncaa Stafe lawe rolm�ng to building mnsfrudion, iehl Fss 2� t�MA P«m.N R ereby o horiz rsprsse ' f this County to eMer � he a v - ned pr er o inspeclio�purpone ' � �g'' SEE REVEIKE FOR E1[RANIhTORY lAN6UAGE ignoluro of ApP Kanl or Age De � z q 0 � , � �, = o • �, �J � � Q c . =;,� p :- � � o b , +, o , .- ^n �w ° � o `�' 'c ��j� m ,C p p f; n ,r �. p �, o �:. ' �o �� � � � Q J p r p p � a � p ' � -,�.�. � n� N '^ , r l \ r • � .°-� �-�'• c -o p (• f � �, o `° � w ,°� °� �m +, f , y O -n .?. 6= p , •0 7� n, �. O .i \O " O � ? 6 o- �p � . J j .i ? . .�.r A � '' � �y , �\' 0 4 i i m� r o ' � ° ^ i • � . . � � !+',� . c n � Q � ` � O 1 N „ r � c� . . . c m� ,. �s-, � � y ip Q c�m T ro{ N G ' " • G ~ 9 '�t 0 o a � n x f C " � � j �. .. 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