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HomeMy WebLinkAbout1363A 2333A VlORKER$'CO!r�EN�ATION CE�IF�RATIpN � � I herrby:,��,m ,�a, � ���.a cr.rfilicaie o��o�,��,,0 5e�� APPLICATI�N FOR BUILDING PERMIT � insure,o�a<c�iiHmic o�Wo�4ers'Compensa�ion Insuronce, or�a c�rt�l�ed copY ihereof(Src.3?W.Lab.C.l COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNn. Compony 9U�L��.'.'G C \ 1\ � Cm��l�r,d copy is he�eby f���ished. FOR APPIICANT TO FILL IN ne�R,SS � �, ��� �(� � Ce�Yf�ed copy is f�led�+��h ihC COUnIY hUil(��nq�nspec- BUitD�NG lion drpar�me��. AD�RE55 Z Z.. Daie nP�uca�� cnv a�� nv /7G'.S� iocnurv � ����`c�, G C `�K. CERTIFICATE OF EXE�J.PTION FROM W02KER5' NO OF BL�GS. nIEAREST�� \ CO:"FFNSATION INSURANCE 54E CF LOi NOW ON lOT CROSS 9, _ $��tj '�Di ��C '� (This seci�on need nor 6e complerrd ii ihe permli is for onr. '1 ns<ESSoa hundred dollo.s(SI00)or�r55.� �RACT 11lOCK lOT NO. MRO gOOK PAGE PARCEL �E�' ` USE ZONE �✓�P I cerY(y rhot;n ihe pe�formonce o1�he work Ior which this OWKER �. ��JR h i[� /.�r��tAn,��� a 1.+�yL+ Np, a pr.rmii�s issued,I sholl nol r.mploy pny person in ony monner qpCRE55 p CCNDiTiOvS � so as�o hecomr suhjrct�o the Workeri Compensation Laws. C1 OTY 21P � Datc Applim � � O - T�� ARCHITFCTOR TEL. DISTRICT GROUP TYPE FIRE PROCESSfDBY I� NOTICE TO APPLICANT: If, af making ihis Cenificaie of Je FNGiN(FR 5.4.�-�.lu1�N0. ��J�I�I i CO�jy� ZONE U Ear.mption, you should become s�bjPct io the VJorkeri ` (� w Compensaiion provisions of ihr,Labor Code,you mu51 forlh- pD�PES�Jro2 Q $ ?� ` V � \\�Cf��'s d wiih comply with such provisions o� this permii sF�all be TEI. StA7iSTiCAL CIASS:FiCA7iON nPT. COn'DO. Z deeme.d revoked. CONiRnCT04 0 NO. — LICENSED CONTRACTORS OECLARATION ��[, QASS NO.�DWFIL.UNiTS I he.eby a!f�rm ihot I om I�cnnsed under provisions of Chapter 9 aDDaE55 NO. �4�Z'f�P (commenc�ng w�ih Sr.cr�on 700p)of Dir�sion 3 cf thc Business and ii�. Pro!ess�o�s Codn,and my licr.nse is in lull ferce and e(fect. CtTY � CLA55 BK � VAIIDATION 50.iT n �;NO OF NO.O' C�{ECK license Number L�c.Closs SiZE �,��� 510RiE5 FAMRIFS ChE ' VAlUAT10N CESCR'PTICN OF WO4K J-d{�E. , ,�v �EW ❑ Conlroclor Da�e S ,���Q�_ O ADD , I am exempl under Sec. � ��.��` �^ A�TER B.BP.C.(or this rnoson V � , REPAIR � f `� �L��; Da�e: E iST NCa 9lDG. �/� J DEN'.Ol ❑ f; . • • e i:: Signolure AVRiCqNT �7 , iFL. FINAL'��/-���J � • � � C,(;: OVlIvER�RUILDER DECLARATION ��'^"�UT1�CL h l C e f'�"1['f 1 vMiO. G I' DATF,�C � I he.reby affi�rx�ho�I am e.emp�f�om the Controctor's L�censr. ADD4ESSa3� N J � ' � � '��`�� � law for Ihe lollowing reason(Se!ction 7071.5, 6usiness and I IlfiC�fi O FINAL �- Professions Code)� .. PRt ENf BY //'. �C�F'^" ❑ �UILDI4G . . •' • I, as owner oi�hx prnpor�y, or my employees wi�h �CDF:55 woges as iheir sole compensalion,will do the work and ' ihe srructurc is nar inir.nBPd or offered for sale(Settion IOCAtITY 704e,Bus�ness and Frofessions Code�. h+OwnG TEL. � � I,as owner of�he properly,om r.xclusively contracting CONiRACTOR NO with licensed conhotlors�o conslrucl the project(Sec- qD�PE55 tion 7044,Businr.ss ond Proicssions Codr.�. . CONSTRUCTIONIENDINGAGENCY SEf�CnCK YARD NWY ���Ap�P�INEF�V•A WiDiH � I hereby alfirm�hoi ihere is a consrruc�ion lending agancy for fuCvf � ihe pe�Iormance of the work lor which lhis pe�mil is issued P.l. (Sec.3097,Civ.C.). SIDE •f L J;.:;r1 P.L. Lender's Name �:e s e a u � lD:'A Ref.M le,nder's Address P.C.Fen S � � �erm�r Fee `, � „ � �'v�)r An I ceriify ihoi I have read ihis applica�ion and s�a�e that�he h.�a�c�Fee ,t.) �Dt�'A V/C M • obo�e informaiion is correct.1 og�ee to comp�y wiih oll Couniy in�esi�ga��o�fee ' � /'';l l`'` ordinances and S�ole lows relating lo building tonslrutlion, Torol Fee O L�.MA Perm.N � F; ond he�eby a�ihorizr.rr.preseniar�ves of this County�o enrer ��� � -<'� up ihe above-meniio�e.d properfy(or inspetlion purposcs. . . . u� �O—�{-�('� S[E REVERSE fOR EXPLANATORY LANGUAGE D ` Signaiure of Appl��ont or+�'. �I pvle ' � ,�..._ -�'�o �. * _—_,e;_.�'�; ' 'y:.�, - �'i� .� l� � i, t �'. �� 1j ' " ti'• � ' '� �I� _ _•w�I�-J�...�f�` If, - t'.��� ,�.- ' q � � � ' ' J, ' �� I .y C� ^ I� CV ' � , p � '�'.�' ' � , � � _!' (i� `a, ' ~� " �i'. ' O � ��a . �+'(�' .n 'r ' . 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