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HomeMy WebLinkAbout1044A V!O�KERS'CO"�?ENSATION DECLARATICN r� � I her�•by o(firm ihar I have a�e�,;�;�o,P of�o�,e�„o,e�� � APPLICATION FOR BUILDING PERMIT �j insure,or a cnrtificoie!o}Vlorkcri Compert<a�ion Insurante, or a crri�fied copY thereof�Sec.3900,Lab.C.� COUNTY OF LO$ANGELES BUILDING AND SAFETY P�olity Na. Company Cenificd copy is hereby furnishr.d. FOR APPLICANT TO FILL IN BUIIDiNG .� ``'> f� no�R¢ss II I ,ei�t'--��,✓Y��-y� FFIi✓ � Cen�find copy ro filed wiih the couny build�ng inspr.c• BURDING /� / "A�l_�l�,�^./�/� / ,(/ 2 �ion dr,pa��mem. nDDB:SS �! J«��LV// /` �„� Da�e Applitoni CiTY �N/J Ziv �({�� IO�AIITY CE471FiCATE OF ExEMPT10N FROM WORKERS' J � NO.OF BLDGS. .+:EAREST � �\�i COMPENSATION INSURANCE SIZE O�lOT i X NOW ON lOi I �RO55 ST. G � y/�J �'�'� ' (Th�s section need no�be tomplr.ted if the pr.rmit is for one /� nSSESSOR hvndred dollors(SI00)ar less.) TRACT Y BLOGK L T NO. !AAP 90dC 7AGE 7ARCEL y� 1 fi � f•fE4 E IONE 1fAP t I cern(y ihoi in the periormance oF the work(or which this OwhFR��C "I � 'o.��� � Np. � r- permif is issued,I shall nof employ any person in ony monner � � �� 0 � SP'C�AL � so as to 6e mr.subject to the Workr.rs'Compa saliop ws. AD�RE55 �` �^r! CONDITIONS 0 �Daie �• '���''". �c X ,/ cirv J/�/11���J �(.t-� 2iv r�7 Lv L Appli[ant �. ARCHITECT OR TEL. NOT�CE TO AF?IICANir If, afr rr�o�i �his Ceni icatr. of �:SiRiCT GROUP ttPE Fi4E PROCt55ED BY O Eaemption, you should beco�ne� �n to the Workers FNGih'fER � 7 h0. �ONSf. ZONE � U Compensalion provisions of th�Lebor Code,you musl forlh- ���5� �,�1/jJ . �T� ,��� �+1 wi�h comply wifh such p�ovis�ons or ihis permit sholl br. �u �- deemed revoked. �/ TE�� STaTiSTiCAL ClA55iFiCATi , APt. CovDp. V) CONTRACTOR �(.I/" NO. �/ Z UCENSED CCNTRACTORS CECIl�RATION ��� G1A55 NO.,_S='LDvhIL.V^�ii5 I hereby o!Fi�m rhoi I am licensr.d under provisions of Chop�^r 9 aDD4E55 NO. (CommenNng wi!h Seuion 7000)of D�v�s�on 3 of thc 8�siness and ��� SEW4R MAP PrcFessions Code,ond my license is in full force and effett. CiTY Cin55 4K � VALIDATION SO.FT. ' !.'O.OF k0.OF CMECK Li[��SONVmbPr LiC.Class SRE STOR!E$ � FAMItIfS I ONE VALU/TIQN OESCRIPTIGN OF Wpqr NEVI � C❑onhnClO� Dale " n� � I L� �/����� ADD s ��� ' I am exemp�under Set. U �� � ALTER B.BP.C.for this reason REPAIR � f Dafe: USE CF C'�•.a ❑ '� Q/i,rl i E%iSTING BIDG. APRIU4NT TFL. /' � Signoture (c2iM�Se J'�iGE'�'(jE ,p ��t� FINAL �� i� • • • • • � OWNER•BUILDER DECLARATION DATE�-��� I hereby aff�rm�ha�I am e.empt from ihe Caniroctor's l�cense / � • •,�,(y 7 j low far ihc following reoson(Sec�ion 7031.5,Business and ADDaE55 �� FINAL �-� Professions Cadc): �E ti � �- 8Y �L�'" • . .3 h 7 5� —❑ ����o�N� �-I P_P�/'.r�fr_c�'ou0 .�.�. s I, as owner of the propnrty, or my employees wiih nCDQESS /,n�!r O�C v-�� wogc�es Ihcir solc tompenso'ion,will do ihe work and ��q��TV �4 7""�''� . 1`�� , ihe s+ructvre is ner intended or offered ior sale(Secrion 70aa,Bus�nees ond Proicssions Code�. rr.owNc iEt. � I,as owner o(�ha praperry,om eKclusivr.ly con�rauing CCNirtnCTOR NO. with litensed co�haclors to tonllrucl�tie projetr(Sec- qD^ZESS iion 70<4,pusiness and Profess�ons Code). � CONSTRUCTION LENDING AGENCY SET BnCc �AR� HWY 1p1Ap40P.iih� � W�Diii I hereby olf�rm thai�he�e is a cons!ruction lending ogency for �;�py� �he periormance of 1he work for which fhis permi�is issued P.L. (Sec.3097,Civ.C.). SiCE v.�. lender's Name �/. ys-- lDNJ1 Re(.X P.0 Fee S Pe•mi1 Fee �o ' ���d�.•:add«:s I certify thot I hava read this eppllcarion and s!ate iha�the �sv�o�ce Fee /�'� io.M.4 P/C M above informarion is correci.I agree to comply wiih all Counry in�eci�gaiion Fee / -f L� ord�nances and Siota laws relating lo building construttien, Toia1 Fee �(O� / J 10.4L4 Perm.M and,hereby authwize represemarives of ih�s Coun�y+o enter /upod ihn'hb6ve4neniio�d p.ope«y�or impeclion pvrposee. ��`�:�////���G�� �/L 3 SEF REVERSE FOR El[PIANATORY UNGUAGE � aro.n af Ap_�N or AgeM Dole . `` � ,a 0 \ ; - {� t� ';, ". -, 1 \ - _: :^ : c � ,� � o � !n = c = _, t� ,, o `°- C1 (; !� J �:: l. � - `, '� O '}. C �`G ('p ~p � c `: i v V, 1 , � ' �� n T 1� .. f f , r ,` f'' f,' n N G (' �� � .. '�L C'O ' � ` .�1 : t� �f ��C'. C � C � �' � 'O ?�' �� , /`.\Z � G , ,� tr 1 �� C � �O �.+. (' � ' �� P. ' 0 7 . , �' � - ' , �`n '� v .c G �I .'�� � •� '�O , � ; „ ; . � n � , � � . 1 �". 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