HomeMy WebLinkAbout1363A 2333A (7) 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 '
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