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HomeMy WebLinkAbout1025A WQRKER$'CO':.PENSATIO'J DECLARATION � �o�,bY o:;;�m rha�I have a cer��F�ca�e aF�o�,e�,�0 3��� APPLICATION FOR BUILDING PERMIT insi,c,�or a certificate of Wo�kers'Compensation Insurante, or o ce.�iiiied cop �tie;eof lSec.�900,Lab.C.) COl1NTY OF LOS ANGELES BUILDING AND SAFETY �r 5 .L � S � Polic No. Compony Cerrlied cepy is hereby f ishe . FOR APPLICANT TO Flll IN 9URD�NG •(L ADDR_SS �za g 6 f G'�,� Ceni(icd tepy is filed rh�he � y bui �ng nspec- BU!�DinG �� ` IiO�de O��men � ACDRESS � y ♦ �I Dalc��_/����PPlicont CITV 1� ZIP LOG1LItv l IO�(�? �ERTIFIC�E OF EXEM.PTIO FROM VJdRKERS' NO.OF BlOGS. niEARESi ,fi OMi'ENSATION.NSURANCE SiZE OF LOT NOVJ CY LOT CRO55$T /' /,�rl�� '~ f �� (This section need not be com,Ipled if Ihe permil is for one ASSESSC , hvndred dollors(SI00)or less. TRAci CIOCK LOT NO. �TAP BOOK PAGE PARCEL �1 IEL USE 2CYE MAP I cert�fy�hof�n ihe perlo�mar+ce oF the work fo�which ih�s C'NN�R �1� ' NO � No. pr.�mi�is issued,I sholl not e.mploy any person in any monner S�FCint a 7o as lo beCame sVbjecllo Ihe V/Crkers'Compensafion lawi. ADD�E55 J/ CONDITIOVS � U Do�e Appliconr LITY 21P � NOTICE TO APPIICANT: If, ofier moking�his Ceriifico�e o( ARCHiTECT Oe TEL. 0'S1RtCT G40ur 7YaE FiR: P40CESSED 9r O Examp�ion, you sho�ld becoma s�blect to �he Workeri FNGI4EER NO. COhST. ZONE V . Compensaiion orovisions of tha lobor Code,you must forth• ��,.g«5 �� �� �?����i I, ��c+.^O_ w / winc �omply with such provisions o� this permir shall be ��y �.� deemed revoked. TEI.p�T . SiAT:STKA�Cu55iFiCnTiOv APi. CCNDO. (n CONTRACTOR O.D�D Z LICENSED CONTRACTCRS DECLARATION r �i� QA55 NO.�DV.TIL.L'NITS I here6ya}firm tha�I am licensed under provisions of Chop�er9 A�DFE55 nlD. (commenring w�!h Seu�on 7000)cf Di��s�en 3 e(�he 6�e�nese or+d LIC. ��'�"�NAP Pro(essions Code,and my license is in full force and effect. Ciiv G . CtA55 P! � VALI�ATION 50.FT. NO. � NO.O� CHECK BK. PG. license Number Lie.Closs� SRE STOR'ES FAMI�IES ONE 3 g n � �• hEw VALUATION Contractor �� �� DESC4!PT!ON O�W04K I� ❑ s �!'�O� ' AD7 � �� , I am e■empr under Sec. � ALTER B.BP.C.far thie rsoson REPAI4 ❑ _ Da!e: USE OF ` CE'AOL EXISTING BL�Co. I� ..(.�- ❑ $Ignoture AOPLICANT T:. FINA OWNER-BUiIDER D'CtARAT10N �����i � � DATE I hereby atfirm�hal I am ezempr irom�he Conrroc!or's ticanse • Law for Ihe following reason(Sectlon 7091.5, Bu�ineee and ACC4E55 ' � Ott - fv—' HNA " Pro!e�slons Ccda)� Sy L� ❑ BU:IDIN^v I, a�owner of�he prFerty, er my employeef wiiti A�:4E55 / ' �jr..Q� ��� 1 wc es os thcir solo com ensa'ion,will do iha wcrk and �«A��TY � /b the s!ructure I�no�in!ended or offe�ed for sale(Secllon I 70/4,Business ard Prafessions Cade�. �1Cv:4G TEI. � I,as owner of the preperty,am e.clusively contracting CCNTRACTCR NO. /C� /nC r ' � with Iicensed eonr.acten�o cons�ruct rhe praject(Sec• �� � �'� '�� O Z J ii lion 70<e,Businese and Frofeseions Code. AD�CESS ' RCCUiRED ICTAL SEi9ACK . I��. C���J j: • • • • o � CONSTRUCiION LENDING AGENCY cET gq�K YARD HWV PROD.LI!.E WIDTH I hereby affirm ihat lhere is a tonstruc�ion lending agency for frtCrvi � � ���J�� Ihe per(ormance of ihr.work for which this permil if is�ued D l (Sr,e.3097,Civ.C.). sioE • e .?j::(:T P.L. Lender's Nomo lD!.'A Ref.M 0 E3 1 9—t3 II : P.C.F�e S �e.m�i Fee �_, �� • Lender's Address g I cenify thet I hava read ihis application and staie that the ieeuo�ce Fee �4 C�� �D!.1A viC� ; abovo info�maiion is correcr.I ogree�o comply wl�h otl Coun�y �nres��poi�on Fce /� ordinan es nnd Stale laws reloting 1 building construc�ion, Tc�al Fee � C () LD4,A Pe�m.M oncf hcreb aulhorizc re ntative oi Ihis County lo entcr pon�he .69ve-men' ne - �opr.rty r inspeclion p rposes. , / � �� fEE REVERSE FOR FX�LANATORY LANGUAGE �• ur_�J�.�Yhn�c A nl pa� n �- _ c^_ `o I ^ c ^.c=' ,i� 1 C' � _ _ � I I c o � = o ° ^ ° n - _ � °� c - --" _ T ❑ � n ', �. ; =c' , '_r C " n ,r; „ _` O -� '' (; � ^ 4 = p _; �' �_ „ c; j D a: c _'" r'�c �: � � �, n I I C,7 r n : ^ �y p,� t: c: :;? C�O _ _ ,j _ I'i � � �:: ^ C � O �G',U -. Z' . 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