HomeMy WebLinkAbout1419A (8) . 1'
\'JORKERS'CO:"•PENSATION DECLARATION �j I
I hereby a���,m ihcr I hovr,a cenificaie of consent Ip se�i APPLICATION FOR BUILDING PERMIT
insure,or o certllim�e oF\Norkeri Compenso�ion Insurance, ��
or a ceriilied copy thereof(Sec.3800,Lab.C.) � CQUNTY OF LOS ANGELES 9UILDING AND SAFETY
P�ol�icyNo. Compony
Cerr�f�ed copy is hereby tum�shed. FOR APPLICANT TO P LL IN qp��Dl��� �f � f Y , /
� Cariified cepy is{iled wiih ihe touniy building inspec• BUitD:NGr`� �'1 �1 , /
tion deparlmeM. ACDRESS�—.(�� �r—J- �L� �7 _ l _ � Q'
- t
Da�e ApplicaN CITY I Z�7 LOCALISY Y�T�Gr'� i � _
CERTIFICATE OF E%EM,PTION FROM YlORKER$" SiZE OF lqi � NOW OY`IOTs CROSSSST �7 � ���
COMPfNSATION INSURANCE
(This settion need nat br.comple�ed if thn permit is for ane TRACT � BLOCK �LOT NO. MqPSBOq( C\ PAGE v PARCEL
hundred dollo�s(5100)or less.)
fEC. US OV' MAV •
1 Cerlify ihot in�he pe.rformance of ihe work ior whith lhis CWN�R . NO. v% NO. '����
permit is iszued,1 shltl no�em�oy9riy pe�sopin'ony monner �� _ L� i.,�/j J SPECint � �
ADDRES� (,.A� I CCNDIilONS'
so as ro be omr.Sub'ec to�he W6 e�s Com ensation lows. � O
Dnle � AppI�I��a�G""'c"'�1��� pTY C a
NOTI T PL CANT: I(, l;er 4ing this Cerfi(itot�/oS ARCHITECi OR TE�� DISIRICi GROUP iYPE FIRE RQCESSt�BY O
E.empion, �jou ihould become subjecr �o the Worknrs' FNGfNEFk No� �J CONST./ ZONE � w
Compe�smian provisione af the Labor Code,you mus�fonh- ADDRE55 "
wi�h co!^^ly ••ti -�:h previsiors or Ihis permit sV�o(I bc � �'�
deeme.d�evoked. / 1 1EL. �'- STAT15TI(Al C1P.551FI�AT10Y APT. 040p. [!)
CONTRACTOR�' �O Z
tICENSED CONTRACTORS DECIARATION � ,�i��/`/ / � �i�. ,/1�� GLXSS NO. D'1��11.UNiTS ^
I here6y affirm thot I am licensed under provisians al Chopler 9 AD�RF55/_///.7 _ � N . }`/,�
(commrncing wi�h SeUion 7000)ot D1vis�on 3 oS ihr.Business ond �i� SEv1ER tMr
Pro�essions Code,and my licr.nsr is in full force ond rffect. Citv :�7< �/�7 ���� � CtAS4 ���� aK � VAIIDATION
9 f SQ. hO.OF NO.OF CNEC
License Number ( � �Lic.Clas '�� � SiZ . STCRiES FAM!L 5 ONE
Y�ATION �
/ DE 'PT:CN OF V/CRK i(� hEy�
Controt�oJ �'- - Doie '� V ;� S
� � 1 ' L�.ACc� ,
I am exemp��nder Src. �
ALTFR
8.8P.C.tor ehis reason . � � b� REPAIR ❑ � :^'1 4��n,'+
U5.OF / ✓
Dale: £%�STI^:G BIDG� ( CEMOI ❑ �;• • • • •�
� SignoNre nPPII�ANT / �H✓�� �u�'�'�?i iEt.�'�x 3�^ FINAL
OWNER�OUILDER DECLARATION ICRINT — n0, 3 S �OATE 2��� � ' '4�a C'O
1 hereby af(irm ihal I am exempt from ihe Confrat�or's Licensa
lnw for ihe(ollowing reoson(S^<fion 7031.5,Bus�ness and ADDa�SS ��- �i'y� FINAL �"� • • •�i ;.���j�
Pro�esiions Codej: �2 h SY L
� 1, as ownn of the property, or my employees wilh ADCR 55 G C G 7—t"'"
wa9es os th�ir sole tompensaiion,will do Ihe work and ,
the structure is no�intended c�ofiernd for zale(Section lOGniiTV
70dd,Businees and Protessions Code). 1.'OviNG TEI.
� I,as owner of the propeny,om exclueively conrracling CCNTRACTO4 h0.
wiih licensed mn�racton to construct fhe project�Sec- ADDe�SS
t�on 704a,Business and Profr,ss�ons Cede).
CONSTRUCTION IENDING AGENGY sEi Bna YARD ��wv ����pRCP.L h�F V,� wiorti
I hereby offirm that there is o conslruclion lending ogen[y for f uL`r+l
�he pertormonce of the work(or which lhis permit is issued v i.
($ec.�097,Civ.C.J. SiDE
v.�.
Lr.nder'S NomC
L041A Ref.K
P.C.Fee S P��mir Fee ��•S� '
lendei s Address
I cerlify Ihai I hove rovd this applimtion and stale lhvf ihe heuante Frn l� .�v lD'M P/C M
abovr,informolion is torrecl.I agree 10 comply with nll Counly Invns+�ga��on Fee
ord�nances and 51a�e lows relaling to huilding cpnsiruclion, Tobi Fee �• O � (DMA Pr,rm.N
and hcrcby auihor�e iepresentmivr.s of this Counry to enter
upOn ebove-��' nffftioned propc�ty for inspeclion pur�o es.
����a� 7 �� SEE REVFRSE FOR F%PLANATORY IANGUAGE
��e Appl�co��o�Agen� Wi�e
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