Loading...
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•_ �� ..��� T T (�T R1 T N T. I � �A T� Y� �iJ T = ` I I Z �I =� o ci ° P �,. o a � �° -, ^ ° c o� e_ ° r_ �, � !� . � c � � � n '�^ T ^� �� 3� �" � Q'n� ' _ J% �';� � � n � ° v L- p �� � c � '� r, O -c�, `�r j ° o �..2•• ,�. O C c - � � �• : � �Z r :� n-� r . � o n' � � .O n i �+ °' � � i>f ' � a I :'� - . . ❑ z N n� o u � �' � � : l� ., o` o . p. .c_ � � � ...` - ' �'. `o nv o � — � (� � T ; . ^ _.� Q. . -- n r. . _ o ,�, o o' o r� � , �� r� � �j N 'w � � � � .3 ° � !v � �� �_ ' � � � _ ' • ^o '� � o 'r" ' � ;n � . � ? � � ;ei 0 i � � • vJ • a . � � �" ,J I o ` '�I I 7 � � O �� ! N �{ I O � � � I o 0 fI N � !. o � I t . 7 ` a' �o a' lo o Z � I ti ___�� ;9 t" --� � o . �� 1 � �:.i i � ., � . i � N O O ' ' �: �j D� � � �� �r � r � � � z ' � � c 4 � v i � �o ' < I I � I G � I i ' Z ' N . � '9 ' � n �1 0 . p � N • Z 0 H ' T N 1 ' q n C� :��0� 't" C ,� �`1 �Z G O •' ` tin�.s +.�.ry � � n- p ^. A 7� C C ` =4 � e: �` C O �1 ��'N: �` U+� �� � r, � �'C .i"..N�N �J i. G i.i �� � C r' .�. �' 7 O ti ei M f •� - e� : �` C.` "'+, n `v^ Z"�oJ .• � N C e: w :� i7�n � ^ O N C ti�� O~ �='� �. 4 f; fJ h 7"�� ` R �., N (� N - .n \ 0�^� �'N 4 Q' a y F _.c. � -N �°.`� � Cri •. � � _ o �T r �`�"�,�'r� c a o'< O�+ ��r.� w 5�� C��'? � ��^ N•N w (� � � .r. � ti ^•�1 w t��i� � � � l M �'� � � ~� � \ �N ? O w \~ti � ti �� q �'A .^�. � � � �'�,�c� ° �`, n �> > a o^ o �n H c i � t �a � 2 « � n �� c . " F ���oon � � o' �titt `.�� T 'C 3 ` a n ei W w'�" ` ...N G a ^ N.� t� ,^� n — n .. � �0 -�.. ��� �•c =, :� M � � o �"S �.�+n c.C G � � n ~ C1 p�L`� � 7 !�'1 C C� ,� : S » �0 � Q C ���J O T C�� w 7 '�N C n C v T � _ ^ �'?~O S7 ��~ � C`r p �. 6 v q �,• `"`4 1\"n C n` '^ �' O� ri -�i �n `° ` w � o n o x =� �F o��� `M ^ "�'�`.i » � }'e c o 3 � '� " �° ° ` o � i�Fc C' � ` � �-� �`�n'� � �'+ ° , c' ' ��od Z ^ F � n� o � c� i ' � o ���< a M ��?��^'��°,S m v (h'�'^i � � �^ �; 3 c-r ^ � w b� 4 r o ry�"`,w �.o� �;H'�� o r,� � N �� � � � x w.��`�n p C �3 �..i1 v:� M `� r p p � 4 U O r' �c M ` a � 3 r. � • z ` � .,.:_'N �"� ^ � �`�'"n.a i � o � O�.^. _`r. � C���^ '� ti '�l o Q ,-,, �+„~. � a i F � C�.o � � o �3 �;•�'�_ � a ? o � f. c r• � 'Ly <' �.��.�� Y�e n � s. L 4 •N `n. � C �� C � � M'? � o �. � „� y �•F �_in� o `~" •�•��: ti��w� � � �f � � , O o � � .< b r.� t,N f-r � p C z .�`' ; yo oc �C ^ = C �n � N �C^�^`ry � VV V7 � o c ''" �• � � � � �'��n Q-n�d`� o° ° '.; '� ��c' o � o 0 - C.•'��i.. � C .\.'�` .n. �O f ��,�~ p'CnC� � �.� �O ,n n O L�3�� p F,�i.�•V 7 ' �� �`� � ; � n �'� IJi . �n f' � � n a i `t a � G.S ' �4 . ?n � : �.: - L`��v�