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HomeMy WebLinkAbout1657A (9) WORKfRS'CO!l�PENSATION DECIARATION � Iriure6orarcrert�ikoieofNJorkenr}Com'peno;o���;�;o�e" APPLICATION F�R BUILDING PERMIT o�o cerulirtd copy ihereoi(Sec.3900,La6.C.) ' � � COUNTY OF LOS ANGELES BUILDING AND SAFETY . Policy No. Company � Cr.�i�l+ad cepy�s he�eby fu���shed. FOR APPLICANT TO FILL IN euno�NG I'�/ Q ADORESS l"7 � Cr.rtifird co{�y is filr.d wilh�ht!toun�y building inspec• BUII�:NG /' � / �j ' tion deporrment. ADCRESS �p Date ApplicaN CiTY Ct�L Cl� "Yiv lOUliTv ��; CERTIFICATE OF E%EMaT10N FRO"A NJORKERS' NO.OF BiDGS. NEnREST �] ��.m COMPENSA710N INSURANCE StZE OF lOT NOW ON LOT :ROSS ST. l�.,�v u— �Q � (This seclion necd not be tompleled if the perm�t�s for one nS5E550R hundred dollars�5100)or Ifss.) TRR.C7 6LOCK lOT AO. 71J1P BOOK PAGE PARCEL lEl.p 115E ZON: �P ? L I certify 1ho1 in Ihe pr,rformance of ihe work for which lhis OWNER n100�'�^ � � ��� J � permit is issued,I shall not employ any persan in ony manner � S�ECinL p� zo as�0 6ecome subjecf fo the Workr�i o/mpen+ntf awe. � ADDRE55 C : CONDifIONS U Daie ^� -an�;ca�� `�'� . •/(�'� atr /G(l� DYL A( zia d � ARCHITECT O; /� � NOT�CE TO APPLICANT� IF, affer mo4ing this Cery�cate o( FNGi�EFR ('/Z4' LiI Ld�tC .GZ�'V(� DISTRiCi GROUP ttPE fiRE PkOCE55ED BY 0 Exemption, you should become subject ia �he� orkr.rs' [ONS�T�.{---. 20tiE V Campensatian prov�sions of ihe lobo�Code,you musl forth• pppo�c5 ef [Zr�b r� I,e,�t� ' U N q W ith COmply ilh SVCh pfOviSiOnS o� Ihis permil shall br. EL SfAT15TICAL ClASSIii ATI04 APT. CONpp. U) deemr.drevoked. COVTRACTOR t/GH6Nt UIf��No�2cA"�� Z L ' IICENSED CONTRACTORS DECLARATION � �, QASS 1.'O. OwELL.L'NITS — I hereby cffirm Ihoi I am lice.nsed under provisions of Chopier9 AD�7E55 � �br�r l�Y 2�� (commencing wi�h Section 7000)of Division 3 of IhP Businr,ss and /'�l� ��� SEv.'cR M'AP Prefr.seions Cede,and my Ifcense is in full lorce ond effect. CiTv `N� CLn55 pK P,. VAIIDATION SQ.F ^� 1.0.OF NO.OF CHECK L�te�se Number'�Lit.Closs�_ SIZE / STOR'ES fn7AILIFS ONE ❑ VALUATION /1 � Cp+�� �'c�b GESCRIPTIOYOFWOPK hEW S ` O � Canlrocicr`�fJj'N(4f� ale � ❑ ��"N rc� ADD , I am eKempt under Set. � ALSER B.BP.C.for Ihis reason Ol r a � � q�pq�q � S ' Da!e: USE OF CEMOL E%ISTING B!GY'i. ❑ $ignalurc APP(P�TI �/ �� - V/� �EO. n7� `G�iJ fINAI OWhER-DUIIDERDECLARATION �J L /1 DATE�' �� I hereby alll.m ihat I am exemp�from�he Cantrocior's licr.nse ADo�¢55 ��� (C�J�•VI � `��� FINAL Low for the followin�rroson�Settion 70�1.5, Business and — . Professions Codc): arrE:n 0Y g•-- � ❑ ewioiNc I, as ownrr of the p�operly, o� my emplayee.s wilh ADGRESS wagns as ihr�r solc compensation,will do�h�werk end � Ihc struclura is nal intrnded or offered for sole(Settion ����TY 70d4,6usiness and Profess�ons Code�. MOVInG TEL. '�� �� ��� � I,os owner of thr.property,am r.•clusirely contraciing CONTRAROR NO. jl • • • s • 1 wi�h licensed confracto�s lo const��tt the p�oje.cl(Sec- qDDRESS ron 70aa,Business ond Profe.ssions Code�. •"` ��\ „ � • i 3(y�� NE(dUI4ED yARD HWV TUTAL SEidACR iRv51 XI ' ' CONSTRUCTION IENDiNG AGENCY seT enCK PROP.IINE wiDTA ' �� I herehy n(lirm Ihot Iherc is o tonsiruttion lending agency for �RpryT � • • •J Cl I::u Ihe p�r(ormonce oF Ihe work for which Ihis permit is issued P.l. (Sea 9097,Civ.C.�. SiDE 0 9.1 9-2� P.L. Lendcr's Name (� LDMA Ref.N � P.C.fee S Pe�mit Fee Lender's Address /1� I cer�ify iha�I havo rr.ad ihis applicaiion and staie iho�the Issuonce Fee ,l 1 Q tD.X4 P/C• , , • above in(ormaiion is carrecf.I ag�ee to tomply wi�h all Counfy imesi�gaeon Fee • ardinonte�and Slate s reloting ta build�ng conshuction, To�ol Fee l�!M Verm.M ond hereby u�horiz rep seniative of this Couniy�o enter e ' upon�he � n propert �./or inspection purposes. _ � /L.7 � / , ^�y�U� SFF RFVERSE FOR FXPLANATOiY LANGUAGf S�g�aturo o�P.pp�; n�o�Aqen� pa�e �� � °;o q '� � �.,.. , C ^ . ? �t`: 11` '' '" ,`,� � '"� `��� '"� '} �.. �` � � `° �r r: c � C tc . o �i���r� {l:( ;� ^ p � t:' i y . ,n �` 7 �' � �) 'i' ���. O ,` ,f !' ,S� O ' 9 � G 1` Y ' 1 �' n G ' :� �'i ��� .. ! � -' , 1 �r cn o �r :1' ' ` n L :o �, . r•. � =� i: „ � Gc.,' � i i: �`1 -t : , ',� 1 N` n� � G � :' � `P�yi��.� �V O i . .��� 1,O � '� C : �= � O a � ,'t �!• � ^C J 7 C C V, :.Q � �, ..( ,� � :�� � �r .� 1, O i % � ! ! 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