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HomeMy WebLinkAbout0840A (4) 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!N3O1DG. ❑ 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 � S�g u.n cl App!�<r.nl or Aa�ni Da'e . . �s ;,o 0 . �T C (] . �r <f� =t�n � C C U •f�• .o ; nv r. a c a o 's n . p �� � N o � ,� o ; T, T ��O 7�' � ✓� �.. t� .'". G 'C7 � ^ , A .� (A O r n � O. p � �' n r- p � o p' '� a � q `� i :M o� o -' Q ' ° .lo r j=' oo � � � G 4. F7�� � H'r�i o a � � � M �' ° �� r, c� "� . "" c �'� ' < ^ o �= , % � � , w< <: o f � _. '. ` n n -�� � . 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