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HomeMy WebLinkAbout1049A �YORKERS'CO.MPENSATION DEClARA710N � Insurebo�afcerlif�a'�eo�Wokers''Cem1pensolionslnsuranter APPLICATION FOR BUILDING PERn►.. _ o�a cenified copy ihe�eoi�Sr.c.3800,1a6.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY Policy No. Compony ,j � Ce�tHied copy is herrby iwnished. FOR APPLICANT TO FILL IN AV�IDiN^v 09 �1/ �ipD�EC�iQs Q AD�JRE55 � Ccrlificd cepy is filed wilh Ihe co�nly building inspec- BUIIDtNG �D tion depar�ment. , ADDRESS Dale Applican� GiTY 21P LOCALITY I�'�1A`.� 2 CERTIFICAIE OF E%EMPTION FROM WORKERS' NO.CF eLOGS. NEAREST SU�SEr' CJPOyS//',� COMPENSATION INSURANCE SiZE OF LpT NOW CN LOT CRCSS 5T. (This sec��on need no�6e complefed if�he permil le fo�o�e ASSESSC4 hundred d011ars(5100)or less.) TRACT BLOCK lOT NO. IfA7 BOOK GAGf PARCEL OWNFR\ /�WC n0 7� USE 2C':E MAP I ceriify ihot in the performance of�he work for which�his h0. 2� � ),; permif is lesued,I sholl not employ o par�on in any monner � SPECiAt p„ so as lo betome s�bject 10 ihe 1No� i ompe lion lows. A��RE55 '/ CC'J�ITIONS � �0f7 Citr /� LP V Dale ��� Applic � NOTICE TO APPIICANT: If ofler ma4ing ihi7 Certifi a19 of A4CHI7ECT OR TE�. D'STR�CT GQOUP ivCE F�4E FROCt55Eo BY O ENG�NEER NO. CO\' 20^:E h Eremp�ian, you sheuld eco eublecl to the Workers' rt V Cor..persa'ien prcvisicr.s E�. Lc6or Cede,Y^u mu!1!Cr!h' ADD�c55 �V �� W winc �omply wilh s�ch p ision7 or rhis permit shall be . deemefJ fevo4ed. TE�� �[ �/ STATISTICAL CLPS IFICATION APi. CON . N CO'�TRACTOR NO.J � fXJ� Z LICENSED CONTRACTORS DECLARATION ii�, � CLASS NO. DWEIL.UNITS I hereby effirm ihai I am licensed unde�provisions oi Chopter 9 AD7ttES5 � C' n0 (commencing wiih Sec!ion 7000)of Divislon 3 of:Fa Business end ���. ^ �Y��R�P Professions Code,ond my license is in full force ond effect. CiTv /(J A GLASS G.' eK �, VALIDATION _a+)ba rf�L�' �, C 3� 54.FT. O.O� NO.OF CHECK License Number �b.�..]�_liC.CIo55 S�ZE STCRIES FAMILIES ONE ] '/ VALUATION COnIrOCtOr,,/ON�V. ,�.�Q�SUXDa1n. CESCR'PTICNO�wO4K T n N� ❑ s�,O4' ❑ N ��il ADD ❑ , I am e•empt unde�Sec. � AITER 6.8P.C.far this reason / ' �pp�q S � USE CF � :� O(-S�'i Da e; EXISTING 2LIX"i. CEMOL S�g�oture A?PLICANT TFi. FINAL �=• • • • ' � 01bnFR-BUIID'.R DECLARATION IPRiNi� NO. DATE J'� � I hereby affirm ihot 1 am e.empt Trom�ha Coniroctar's License � • •�l 9.C J low ior Ihe following rnason(Section 7031.5,Business and ADCeE55 FINAL F � /�ssions Ccde): : r: 8Y � .. .l:�.^;� BU:LC!":G I, cs ownrr af�he propeny, cr my emplayces with ADDRESS ��C:i—ii J wagPs as the.ir solr.campensaiian,will do�he work and ��A�iT� , �he s!ruciure is no7 intended or offered for sale(Section 70d4,Business and Professions Code�. �:OviNG TEI. � I,as owner o(ihe prepr.rty,am e.clusively connoc�ing CCNirtaCTOa NO. wilh Iicenled coniraclors to con5truct ihe prolecl(SCP ADD4FS$ �ion 7044,Business and Professions Code). CONSTRUCiION LENDINGAGENCY SE7 BaCK �/4D HwY �U�AFRC?iinE� V•� YlIDiFi I hereby affirm tha�there is a consiruc��on lend�ng a9ency for FRCNr �hn performance oi thr,work fo�wh�ch�his perm�t is issued a L. (Sec.3097,Civ.C.). S:DE P.L. Lender's Name LD!lA Ref.N lender's Address P.C.Fes S Permi�Fee , I cerf�fy thal I hove rnad lhis applicotion and s�ale 1ho1 the ISfYOnCq FP.q 1�. Q LD�.W PiC M e6ove iniormaiion is correct.I agre.e lo comply with all Counly I�ves•�ga��on Fee . ordinances and Slate laws reloting 10 building consiruction, Ta�ol Fee � L�MA Perm.M ond her by aulhorire represe.niaiives this Counly lo enler , �pon ..ob -menti ed properly r inspectian p�rposes. i 9'?3� SEE REVF�SE FOR FXPLANATORY LAHGUAGE � Sipnalure o�Applicanl or A nl pp�s ��; // '�s `S v �"� c C'- c, =' ,,�'. , • ,�--! � '^-• = c v :� r�' �': v �i� .F r �� � � � ' _ o �a l� �1 �� •� S• 7 � (n, 'l• r `. • �`{• yi ,\ ` r, .� � �1 �'C , r� �ti 7 O � P � _� � C � C C <, .: ?,� t7 �= C f� � C • ',1 .�1 f'�� C !` _ r?'1 �1 ` =�- Gy i 1 ��`Z 1 �:._��,^ � ..,'f Jw _: - N � ' � �� ' !'' 11!�D �1I-^ n7 �^ �` 4fC i '� L .� ` ' t %tt, a ,'C x ..-; • � . �• _ ',�� �' � � ;o t` ��;" � �' 4� � r C,� , •+ o :� 1 � . + '�o o. 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