HomeMy WebLinkAbout1214A 1VORKERS'CO-4+.PENSATION DECLA4ATION lI
I hereby offirm thci I hove a ccrlifitale�f consen�io self APPLICATiON FOR BUILDING PERMIT
ins�re,or a ceriiiicoi�of 1'lorkers'Compens�ion Insurance,or
a certified copy the.eof(Sec.3?00,lab.C.) COUNTY OF LOS1ANGELES BUILDING AND SAFETY
PolicyNo. Company
� � Cemiied copy is he�eby furn�shed. FOR AFPLICANT TO FILL IN no^RCSS 3 � 4 LC ✓U�
� Cernfied ccpy is filed wiih the toun�y boilding inspec- BU�ioinG '
iicndepa�'ment. aooGe55 `�, /f'U`GtJ/CL C /U� iocaurv �1f}fi1 t� ��1/'�
DO�e Appli��n1 ��Ty NE�REST
l3 r� Z�o q �s �RosS ST. u 0 ru ..�c�c�
CERTIFICATE OF EXEI:•PTION FROA1\•lORKFRS' h0.CF BlDGS. n55FS504
CO."dPENSATION INSU4ANCE 5¢E CF LOT NOW ON LOT 1,!AP COCK PAGE FARCEI
(This setticn need not b�ccmple!ed if the permi�is fo�onr.. l �" use ZCnE +•�nv C/�
hundred dollors(5100)or less.� TRnCT� � I?lOfr LOi NO. ��1 �/ n0 � / — �i 3 }
IFL. / SfECIA� �
I certify thai in the perfermance o!the work for which Ihis OW�E � �{�Q�C no. ._9y-y �J . 'U COhDITiONS �
permit is icsur.d,I shall nol r,mploy ony person in any monncr � D Ui512iC� CiRCUP �YPE Fi4! I�i2UCESSf�BY �J
ADDQE55 • '� I � LC_ CO.'.'ST. ZCf`".
so as b aco�^r.subjPc�b ihc\Yorkc Compr.nsa�icn Laws�'j � �
^I/�.JJ �/�� �7 � � `" Rt� 0
Data. L1�Applitanf� � .�f/^'— I CITY� {�. A� ZIP I/`� S1AI�11CAL CIA��f KAIIUN / �APT. CC`NDO. U "
� NOTiCE O�AFr'LICANT: I(, aher making �his Ccrtifimtr. of ��Cf�RECT CR TEi. ; ���
Exemption, you should 6ecome subjr,ct fo thr, lVerkmi FNGI�EFR NO: CLA55 NO.�DR'ELI.UNITS_ �� �L
Compr.nsoticn provisions ol ihe Labnr Code,you m�sl forlh- „G�*ESS � bEv;Ekl.taP Z
wiin comply wi�h such provisions or !his permi! shell br, —
decmed revoked. �E�' � pK. p�, VALIDATION
CC'.'TRACTO4 v'�� NO.
IICENSED CONTRACTORS DECLARATION uC.
I hcrehy cffirm�hot I am lic�nsed undcr provisions o(Chapicr 9 AC�RFSS g (1'�� NO. VqLUATION
(commr.ncinp w�ilh Sr.clion 7000)o�Division 3 n(1h�Business nn�! ���
Pro!Pssions Cod=,ond my I�censr,is�n full force and nFfr,c�. CiTv [�nSS S �y .$�QtJ `��
SQ.F7, NO,OF 1 NO.CF t CH[CK
Li[en5e Numhnr Li�,CIt]ss SIZF STCRIES f FAA+ILICS / Cf��
S
CESCRIFTICN(;F WCQC OOIY1 Fl�17 � NFY! '
Controcicr poic O
� I om ezempt from Ihc licensing requirements os�om a [,♦ ti AC� ,
licensed archi�ect or a re�is�ered p�olessionol en�inr.er � ARER � FINAL// �O
oc��ng in my pro(essional capoci�y �Section 7051, (�'1 F�Pni� � DATE �i
�usiness and Professions Cod=�. USE cv � ❑
E%IiiiNG BLDG. � pEr,•.OL FINAL
L�c.ar Re�.No. Datn AfP�ICnNf IEI, / BY � �
O:"/NER-9UIlCER DECLA4ATION (F�iNil � f NO. - �J
I herehy o!(irm Ihot I om e�empt from the Conirocror's Licensr qCD�F55 � � h �< <-L � !l/« N J��C X �T, R�2'�.�%�i
Law ior�hr,(ollowing rcason�Sec�ion 707I.5.B�siness and p��
Pro(es onsCodel: ' ;:�hf ��c. CLrY�G�� �j�'� • • • �
2Ui�D�NG /
�W as owncr oF fhc proP'rfy, or my nmpioyees wi!h aC�.E55����! �I��C_N�L�
ages as their soln comp�nsv�icn,will do the work ond / ' � � • 1 3 9.5 0
ihe struuu�c is noi inrended or cffered(or snle(Sr.cuon IOCAUTY �-� � � � � .
70EE,Businrss and Professicnz Code�. �+.OVi'�G TEL. " . • • � , S(�.J O�
� I,as owner of�he properiy,am e.clusively con�rociing COtiiRACTOR Np � '
wi�h licensed con'rnctars�o cons!ruct the projecl(5=c- ADD4E55 ' � � `� � ' O�.O 7—II 2
.iion 70E4,Buslness and Prolessions Codc�. . � '
CONSTRUCTION LENDING AGENCY �'ECVI.EU YhRD HV:Y �OTnI SEIenCC FRO^A Ex15i.
..Ef�ACK C�C;F IIf�E iY�DiH
I hereby of(irm tl•oi iherr.is o tonsrrvc��on Inndin�n,ency(or Ft�+.��f � � d�
the perfo�monce ol fl�c work for whi<h ihis p^rm�r is issucd v i �� � �d �� �
(Sr.c.9D97.Civ.C.). .S��p " ' ' � �
P.l. '
Lend�r's N�me �./, "� � • ' �
P.C.Fen 5 Parm�r Fre . C V
Lender's Addrrtss �
I crrtify ihot I hnve rcad ihis appl�cn!icn nnd v^iC Iho1 thf! � Issu nr Fn� ..�rG� �
o6ovr.inlorrnaiicn is cc�rect.I ngrrr.to comply wi�h oll Counry in�c5��nn•�on Fro n� !' �
nrdinonces and State lows relo�inq to build�ng construciion, io�nl fee �3�.�U �
ond he�eby authorize repre:en!nrives of ihis County to enter
upon r,o5o•.e-ment'^ned pronnr.rry for Insprct�onIou� cs^s. .
�Q�(�Q,�2.� ,j(� �Y SFE REVERSE FOR EXPlANA70RV LnNGIIAGE /
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