HomeMy WebLinkAbout0840A WCRKERS'COMCENSATION DECL�RATION �
insvrc6orafc'crlifca�clof�NlcrkerseCompensioolnsu���°eso'; APPLICATION FQR BUILDING PERMIT
o ccr�ificd copy iFrreo((Sec.3500,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY
PclftyNo. Compony
� Ce�tified copy is he.rr.by furnithed. FOR APPLICANT TO FILL IN nceo�s5 .����' /t� 1�/' -u�i�n .C�/L•
OCerlified[epy is filed with the county building insprc- BU�ID'NG [� O n . �� " "
�icndepartmem. ACD�E55 ,7�,Z /v' /"/�Uj C O/[J / � LCCALifY �s-,�,r>.1� ,CJ...tiv
Date Appli[ont CITY r yN N� Zlp h,AREST
9� 6 s caess sT. .�.G .�-�•.�-v
CERTIFICATE OF EXEM1?FTICN FRO,".11NORKE45' / ��� NO.CF 91CG5. P.55555CR
CO"!•FFNSATIO.'J INSURANCE S�ZE OF LOT t�D � NO'.ro CY f0T �4AP BOOK PAGE PARCEL
(This se.ction need not be compl��ed if�he permi�is Icr one � USE ZCfM1: h1Ai'
hundred dollcrs(5100)or le!s.) T�ACT rP�� B!OfK l0T NO. 7� A�� ti0 �Z� '..3�� }
IEL i. S�ECIAL 0.
a:•:n�ee 'C e/�.r�/�/ No. s/S G 2 � ��Ta ceNoinctis
' I cer�ify ihat in rhe pei(ormoncr,of ihe work!or which ihis �
� pc�mit is issued,I shnll no�employ ony pe�son in any manner uiSrR�U G40UP IYPE fiRE FROCESSED BY V
so ae�o become sub'ect io the Vlorkers'Com ADDGESS .�r/�.t CCN$T� ZCN
I (�^nsalicn Laws. /� �� � d'
/���,, ��/ ��J� AI � Q�t.I.eA/ 0
DoIC�L_Applican� •-�"�"^ C///��'f� CITV Z�a SiAi15TICPL CLASSIFIC�IIIUN APi. CC4'DO V
ARCHITFCT OR - TEI.
NOTICE TO�1PPLICANT: If, ofler mokinp fhis Cenificoie oF FNG!NEFR �O. CLA55 NO.�oweu.uNiTs_ a
Ewemprion, you should become subjeU �o ihe Wcrkeri �n
Compensation pravisions af the Lobor Code,yau must forlh- �D��FtS '.��F;.,.q� �
wiin tomply wiih such provisions or �his permit sholl be �
IEL.
VALIDATION
d^Cmed revcked. cONT4nCT0� Q NO. CK.Q PG, .�...i
LICENSED CONTRACTORS DECLARATION UC.
I he�eby afi�rm�hci 1 am I�ce�sed undc�pro�isions o(Choprrr 9 AD�aESS NO. VALUATtON
(commencing wlih Srct�en 7000�of Dlv�s�on J of�he Bus�ness ond� ��� .
Professions Cod�,ond my Ifcensc�s in fuil(orcr.ond eHea. ❑rv � C1n55 S ��� ��`l
so.Fr. No.c= No.e� CY.'CK
License.Number lic.Class °�ZE STC41E5 FA:!IUES ON'
� NE1N � 5
CC��roC�Or p��p DFSCRI7T:ON pF lVCRK �/}C�[. '
� I om erempl from Ihe,litensing requiremen!s os I om p 1.�/�.�Ic e � � � r� Ae� � '
licensed architect or a regis�ered prefessional enginenr �� �� � J'�G�� ALTFR � FINAL
ac�ing in my prcfe!s�cnal tapaciiy (5=cticn 7051, ��V4rJ �JD/� , R�PA�R � DATE2�Z7�2
8usiness ond Professions Ced?). use e� ��„Q� FIN �
EXiST!N3B!DG. ❑ BY �
Lic.Or Reg.No. Dale AP��iCANT TEI.
O'.YNER�BUILCER QECLARATIOY I�R:4T� Np.
I hereby ai(irm thaf 1 am e.erp�irom�he Conrra:toi s License �
taw fcr the following reason(5ec�ion 7031.5. 8usin=ss and ADD:E55
Pro�essions Code): :��„ , '
� � I, as owner of�hr. prcperty, or my employees wilh qp^¢;<_5
wagez as ihe�r sole comprnso��on,w�ll do nc�wak a�d �O S n.O A
�hc s�rucwre is net tn!er+ded or oi(ered(or sole(c�;�;a� lOCalirv . ,
7044,Business and Profr.ssions CodeJ. �•.OVi�:G TEI. ti• • • •
� 1,os owner of Ihe prepeny,om excl�s�vely controcring CONTRaCiCR NO.
wifh licensed ce���oc�ors to cons•ruct ihe projecl�Sec- ADDRESS � • •�� 8'S�
rion 70�4,�us�nr.ss and Profess�ons Codr.).
F(CUi2ED IO�ALSEIB�ICKFRC'.� E%IS�. •.•
CONSiRUCTION LENDING AGENCY <E�gq�K YA4D li:'/Y pqUP.I�NE l"JIDiN � � �5 O�.
-I hereby of(irm tho�t�,�rr.is n cons�rucr�on lending oc,^ncy lor F.l��y� ' � 3 0_$,
ihe pr.rformance of ihe wo�k for which�h�s perm�i�s issued v i •
�S�c.3097,Civ.C.�. . sicE
A.L.
Lendcr's Ncmc A ,�./�
P.0 Fee 5 Ferniit F�c C�, �""
Lender'S Ac!dress�
I cr.rtify ihot I hovr.read this opplimnen and siaie thai ihe issuo�co Fe� � J(/
obove inlo�ma��on is cor�eci.I n��r.e�o comply w�th oll Ceunty in�esi�on��on hra
�o�d�nances and S!aie Inws rela!�ng io bu�ldmg[O�sbut��cn, 7oial Fen f�v 0
�nd herr.by authorire rep�esen+a���es of ihis County io enier
upon the obowo-menuoned prcper�y for fnspecticn purposr.s.
J�_¢,k ��—�.-�� SEE NEVERSE FOR E%PLANATORY IANGVAGE �
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