HomeMy WebLinkAbout1215A 1216A (6) i•
\'JORKERS'CO'.1PENSATION DECLARATION �
I hereby o«�.m thct 1 havc a crrtificole o<<o�=��,fo s��� APPLICATION FOR �BUILDING PERMIT
insure,er a cerlificote oi Ylerkers'Co�penslion Insuronce,or
a ce�r(ied copy therecf(S�c.3?00,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo, Compony
OBU�ID�AG �G
CerYGed copy is he�e6y furo�shed. FOR APPLICANT TO FILL IN n.,caFss ✓��.3..� titG. .L
� Certilir.d cepy is fil�d with�he county build�ng inspec• o�ilD'nlG /� �r
fion deparlmr.nl. AD7:E55 � � ,( A/Z,�� LOCALITV '�"�'�"'�rh-+L /�(,{�
Date A li[anf CITV �1 NEA4�ST lt ✓
nn �A a� IIP �/�4-� CROSS Si. �� �t[
CERTIFICATE OF EXEA'.PTION FROh1 WORKERS' NO.C�CtDGS. , 1 .455ESSOR
CO;+�FENSATION INSURANCE Si2E OF lOT NO:Y O`J tOT � !.!AP?ppr CAGE PARCEL
(This se.ction nr.rd not 6e compleir,d if the permil is for one USE ZONE n'•Pv
hundre(1 dCllars($100)Or Iess.) TRACT BIOCK LOT NO. �� NO /n��3�3 }
n iEi. G sreuai a
Oi':�ER 1` 2 NO. -�I ��- O ��T COVDIiIONS
I ceriify ihol in ihr.per(crmonc�o(�hc work for which�his 0
crm�1 i5 isSued,I Sholl not em Ip nn ^ f� U'S1NIC1 G4Ul1P IY!': FIRE PR ESSED BY V
p p y y pe�son in ony monner ADDC;55 c� � 1 )�U�. �LL CCNST_r ZC�' K
so ns fo 6ecome subjrtcl to Ihe NJor4eri Compens C�lpws. t
/1 f�� /[7 �C"i3 / (c,ccr� p
�2 -� �C(.C��"L�CECC�— arv �fl nr Q/7(�S �
Da�a� Applicon� sTntisncni unssiricniiov pci. COV�. V
NOTICE TO APpIICANT: If, o(ier makinq this Cer�ifica�c of �2CHIiLCT CR iEl. �' W
EMcmption, you should br.come subjeC� to ihC 1"Jorker5' ENG�hEER ItO. ClAS$1J0. f" CWEIL.UNIiS d ,
Compensn�ion provisians af thr lchor Cod^,yov musl for�h- �;��R'�� SEv:E4.".:nN . 7
wi�h comply w�lh such pr0��sions Or !his permil sholl 6r. � �E� '—
deemed revoked. CCNf4qCiC4 �N�C No. PK. rG. VALIDATION
LICENSED CONTRACiORS CECLARATION ���_
. I hereby cfHrm�hnt I ori Ilcensed unA�r p�o�isicns of Chopter 9 ADDRE55 - 1'h� n:o. VALUATION
�commencing with Section 7000�of Division 3 of Ih�Dusiness a��l LIC. q ✓'
'7,;essionx Code,ond my lice�se is in full(orce and ef(ect. CITY C1A55 3 .�C �l' `� .
'�,�i� SU.F7 !,10.OF NO.CF C�'!CK
�.rnsc Number Lic.Closs SIZC STC41E5 � Fn�!RiES I C4f
/: nLVr 5
./. �ESCRIPIICN CF WOPC
��on!racicr Daie ❑ .
� I om e!.empl frcm Ihc licensing�requiremenfs as I om o , �� %•CD
licensed orch�ie.ct or n reg�stered pro(ess�onol eng�neer a��FR ❑ F�NA� /I a� (n ?�2�.5�
ncring in my pro�ess�onal cnpatity (Secrion 7051, �(.,�'�'�, ( LL � �ATE tSC/
� 6usiness ond Prc(ess�ons Cod��. u��CF cFvn�a i
Ex15iIM1G 21DCi. CF.'.'.Ol � B1NA �• •�• •'2 TJ
lic.cr Reg.No. Da!e aFruUaT iEi�J/ Y
OIVNER-BUILDER CECIARATION ��'7iNT� �L°K �- NO. • �/-�/�/& � � � � Q O O
I herr.by affirm Ihol I am e•empl(rom ihe Conlrocior's license nCD4�55 ��J � +�-l���-�— � ' ' ' � Q���
Law for�he following rcoson(Seciion 7031.5, Business and �"
Professions Cod�): � � ���+i 0�.Q'��8 2
❑ . . 9U:�DING � E. rL� '. � ,.
I, os ownr,r of thc preperly, or my employees wilh aC��E55
woges as rhe�.sole comp^rs��icn,will do�hc work nnd . ' ,
�he srruc�ure is nat inter.d=d or offered for sale�Secf�on �«A��TY ' , �
7044,�usiness and Professlens Codr.). P.^OV:NG 1E1. � � -
� I,ns owner of Ihe prepeny,am eMclu<ively con+mcting CO\7RACTCR � N� ��2�,6 A �
wirh lirensed CCIIIIOC�OlS 10 COf151lUCI IFIP projecl(Seo- ACDG'_SS
tion 7044,pusiness and Professions Cedr.).� #�� •,• • •t
CONSTRUCTIO'J LENDING�GENCY F�E(:UIRED yr�D H�;rv �OTl1l SE70ACK f4(7'A Exisi. '
SEi P.A�K FRC7.I I!�� V/!CiN � • .� 6 5
I hereby offirm ihat�herr.is n cons�ruciinn lendinq agency for �w�Nl . � �
ihe performence of�he u•ork(or which ihis permit is issued P t
(Sec.3097,Civ.C.). SICE � •,• •1 6 5 0 u
P.L. .
Lend^r's Nome • Q�.Q 7'$Z
P.G Fee 5 - �i� Permn Fne • � l��
Lender•s Addiess p /'
I ce.rlify thal I hove mod this cpplimlion and s!alr.fhol Ihe IssonnrrtFee O•J/v
� obove�n(cnno�ion�s m��ed.I o9•ee to tomply with oll Cooniy io�es��nc��n�Fan �
2 ord�noncrs ond Sia�e lows relating lo bu�ldinq consiruc��en. }c��l Fee �G. �r0
and hrreby auihorire r�presenia�ives of�his Ccun�y to entPr , .
� �� upc hr,abave•men�i ed prcp�rry for inspetlion p peses. , ,
� y v'� �� �,�1 Lp,� �2 SEE REVFRSE FOR E%PIANATORY LANGUAGE � '
� ' S�qna�vre ef Appl�co�l or Agvn� Do•_ ��
..���
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