HomeMy WebLinkAbout1214A (6) 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 /
Sicnnluro C�ApolicaM or Pgenl �otrt � � D/
i� �
` n c
' � I
^ T � .
V�
� o �9 �c � o � n w
,� r j ,C�, O [� 7 .. CL p s '
r �^ •• C C f.c � _ � � O �'� C7� � Z) L' �^g , r %
r. �.'. C U fl 7 � 3 .� 7 fG.` �•D: 47 7 p 0 � 'tl �` L
�^ ^ C � tR R. U (` �^ � 2! U 'a O� � � n 1 p
f� p ` � � �C •• 7�"� � 9 ' 1J ❑'D 7 � n i � e I O
O I �= K .ri.K j `1 C �•s O, O O � O O � Cv P n.
- Z �V e - � _ v n
+i roa � p fp _ ' p M , Yo =^_ ? M
O � C � i � " C . � o r
7 �Q ._. . . t � y
° _ � "� �
a i r+ �- ' i ^ v�
u. �
)' ,� �o O
t/� ✓� � � C r—�.[ R ' I'
� (� .� �. J �,' n � w 17 1 e� rt,`-
s- r f f ea! i U �� �• � (1
'6 ' � �� p !� U �
cY v � W o a ;� �
� ✓ � � �l i ~
�3� � ' y �� i
^ Y-{� r f " s' � � ��
. q
� � r, •^ qo A
I �'
i �
L � , N � 4 . 9
�jJ` � V: � .r'.. �I .�[
\ . �• , Y^ O � H
� 7 O'6 j O'
�� 1
C �
U
:1
z
. i
• m
n
� .
0
. �
• N
. «
�
, n
N
f
� .... � w C�.�..'i C`L�"�t� � l�`. T
�y �"i �.w L� �n O �-' " "= ^ '^' n .. t.� {. h v f
n.,� C�=O�. L'`._; L O � y.�. _.� � �n�N l��'+� � �'V'�i C 1.i...�: F �" O'
� 0 n O .,. ` n ✓.t�' rJ': C..� w f, ' +.7, p r- c O _�'•��� O.�,,,t^'` � t � �� Q
r, p � :. �M.. f C. A`i; :�L"..�p n i�„ n u� • �i F �"..�.. •-.C: z+s• � O�
0 � +-� �� � � �. e' t. � O �c. � � n'n�lr r. � _:']
a a_ c` F '•cN ^a _ lr � �'" N"" ��N'r� �� ''C^ �c:~ � o� tT"'
�!� �! •"' �` G :�`. �
3 N .:.2 � � � O O�^ C`ti � "G ^7 N 7 w 't O N n'ti L:.y� ^ I+ _.•�
m ,,,a'? c.M , £ �� �� � � :."`�-�c o �� - a � ,,��,-�i�,. r � c M =� C
o "•4 ^� ^. C. [:-� ��c o i�" � �4 N :i r .0.. �� eY,' c e N C`n c � � '
� ? ^ �''. - c..^ o ` a ='°. � ? •� o c_� �= `n-+ac..M � o° C7
. ;s + � ..� ...� _ aa'� a: " ; o ° � 3 � ��, ❑ir.`wC-�: -�, S .; n ? T`t
� � �r. -,- w�..G ="� C ��.. n"O «�, ��i• M p'� C O� N
N �. �L' 'a'`O,y `f' ^•y t. � O C 4 7 O ~C O 19 "` C i:~ ��,r",` �'O C
v o F :: ;'� H o o ^ c ' �Q c K c.a o'o o�.?U^ ''Y c w:,� 3
.�a n ~�� ^ o� a �F ^ c..� c,� n.°.o< � � � � �'�10�•� �� �� C�'
n �-�. - a o e', e y R .._.> ti � V N �� . .� ` n .,,�,
x "i:� � o -` ,��„c.= ° 'oN•.°�'c £ a �e':.� =�aone ` ' o ° ^'
F � � ° ^�N ° �.�.� c ' = .�, n n'_� �,� �n a N = �.,,, ='�c ? 3 ''•
� �
O c= ^c n � ���' C"�^` a � a'< c'� � c.'E' a °`'` n ° „ �O
�I Lr � !� Y tw� _" n N U rJ w�`.�..'C` .n. �,i p'. C N
' m � ^o � 1� ^ �'� �y o �t � O j.3 si^ � �' 4 3�" t,,,�..'' C � Cl 1
N � C 3�,n n N i � C « 4 � G r ro h � V F �?a vC,u. p �� j
f � N Y'S < '..'�.'.�C � ;S O ^ �.. � 4 � �4 V
� � sK. .^,5 ° p.< � ��', t `O� ^ �.°allo° "'�we'n^� S �,P''�
- � -� � a �-L � - �.C"• � �, o� � -�- • �,
n �c t � � � 0 3���'� k � O� f �r C-L••^�� � � : � L'•'L'� u�
. 0 '�4 fi � `,., Z 3 O �� >p.S``•:4_ o � •
�
ti �
T �� � a'� O ~ �^~ , ,
� C
!