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HomeMy WebLinkAbout1547A 1905A (9) \YORKERS'CO•'T.PENSATION CCCLARATION � ��,:nY o��,.m that I ha��o������,�a,P�<<o�,e�„o,P�F APPLICATION FQR BUILDING PERMIT � insurn,or�cnn�ficac o1 Vlorkcrs'Compensaiion Inswonce, or a cerhhnd copy�F�erenf(Sec.3A00.Lab.C.) _ ,�Y�t�Z���a�Y �.^��i�_� COUNTY OF LOS ANGELES BUILDING AND SAFETY U Cend�ed copy�s hereby iurnrshed. FOR APPLICANT TD FILL IN 2u�m!r�,r,� ` C `�� AD�RE55 �G �eri�f�rd copy is flled wiih ihe tounty b�ilding inspec- P.U�iDiNG '.� � o�deportmenl. AODRE55 � � -�{���j��y_7' Date�Applimnl 1_Z��t� `:�7( 1,A�I!� CITv� I� �i� r.� zIP �(� IOCAUTY Q: "V� ,ERTIdICATc OF ExE�1.PTION FRO!.1 WORKERS' NO.OF BlDGS. NEAREST � CO!f�.PENSATION INSURANCE S�2E O�LOT NOW ON LOT CRO55 ST. (This eeuion necd no�be mmpleted il thr.permfi is 1or onr. -7 � n55E55C4 hur+dred doliars�3100)or 1e55.� TRACT � � �B:p[K LOT NO. '� /N.qp y00K PAGE PAR�FI �E�" U�E ZONE r.wv CWN'.R i�^i f ���x.r'�,J�;�1tao.�.'-✓�7- 7 r I certify 1ha1 in the periormance o��he wor4 fo�which this NO. a. permit is issue.d,I sholl nof employ any nerson in ony monner SCEC�AL so os lo become suhjrtct lo the VJCrkers'Compensalion lows. AD�RF55 _ � CCNDiTiONS � Dafe Applimnt CIfY 21P O NOTICE TO APPIICANT: 1I, e(tr.r moking lhis Cerlificatr. of �RCHITECT ORf� �El. , �, DISiRICf GROU7 fYPE f�4E SSED BV F� FN�in!ER FS � NO��Z.> 7 ERempiion, yo� should become subjecl �o �he Y7orkers' � f, C N�,1 ZOIvE �� w Cc.^..p^^:a!icn prcvi:ior.s c1!hc lcbcr Cede.Yeu rusf Ior7h- ACDRE55 � I r � �V � `'~ Q ti- wiih comply w'Ih such provisions or this permil sholl be -� fn deP.mrtd revoked. � �� y�_ �T_E�Q��r � r STATISTIC.4L CIASS�FICATION APi. CO�:DO. Z CONTRACTOR i t� r�0. f^1 — LICENSED CONTRACTORS DECLARATION �� '��� y CLASS NO. 0`1htt.UNITS I herrby affirm ihot I om licensed undrr rrovisions of Ch�pie!r 9 ' AD�RESS��Q ��v NO.-'� (commrncing with Sr.c�ion 7000�of Division 7 of�tie Business and ��� � SEv,4R rrAP Prolessions Cad�,and my license is in lull force and r.ffecf. CITY ��L.� �/\ CLA55 �.-.�� VAIIDATION � SQ.FT. 1 NO.OF NO.CF CMECK BK' �'' licnnse Numbr.r � + Li[.Closs G�� SIZE STOR!ES FA.MIlIFS ONE (�L�� -N�e t77�i.�/�ore 1 U7.1f� ❑ sALUAT�J,� �o���o��a�_ � �� � DESCRIPTIOV OF WC4K NEW � � � � ADO � �I am e.emp�under Sec. J T � _- 1 a�L ALTER � , .--� r,j:,7 f: 6.8P.C.(or ihis reason REPAIR � S v Dole: USE OF DEMIX 1-� .. • • • e i� ExiSTiNG B�DG. U $i nOfUr@ AFi'LICANi I TEL. . 9 OWNER.6UIlDER DECIARATION (F2:NT1 i lr�L F��l�L!� L 1 NO.� �I^I i ( FINAL /'// G �/�� I • •-l.^�) DATE 4.7 L� p/ I hereby aff�rri�hat I am enempt from ihe Contraclor's license � f� • c o�_�;';��? low lor�he faliowing rcason�5ectian 7031.5, 8usinnss and ADCRE55 . ��-� `�.-�f�-�- i��L`C.� FINAL ' Pro(essions Code.�: 4. N BY �� ��.� �-;:�? ❑ P.UILD'NG I, as owner oi ihp property, or my employees wilh nDDRESS woges as ihcir sole compensation,will do rhe wo�k and � � Ihe slrutlure is no7 in7ended cr oiicred for sole(Setrion LOCnLiiv 7044,Business ond Profess�ons Codr.J. MOviNG TEL. � I,os ownP�of Ihr.preperly,am eKclusively conl�ocling CONTRACTO4 NO. wiih licensed contractars�o constr�c�the projeU(Sec- aDD4E55 �ion 7044,Business and Professions Codc�. CCNSTRUCTION LEN�ING AGENCY SEi BnCK YARD Hwv 1O1AOR0�iivE WiDiH I hereby af6rm that fhere is a conshuction Iending agenty for fRCNi %'� Ci G^r the perfo�mancr,of�he work fer which�his permi�is�ss�ed v t. ' (Sr.c.3097,Civ.C.1� � s�oe ,. �. • . • . a j P.L. lender's Name � a ��� n LD!1A Rel,y `'C lender's Address � � P C.F.e S � ,� aerm�i fee _ •�. o�!;:.l:i��: I certify ihar I have reod th�s applicarion and s�oir.�ho�ihn iesue�cw Fee tD.MA a/C M ' a6ove informotion is correct.I agree lo comply wi�h oll County invesi�ganan Fee C 9�=�%-i+� ordinonces ond$talc lows relaling lo building co�structio�, Toeol Fee � Q L��M Perm.M ond hereby aulh re�ep csentaiives af this Counly lo enter upon Ihn ab� me on}d property(or inspeclion purposes. . � ��� ��� SEE REVERSE FOR EIfPIANAtORY LAMGUAGE �ti _������_S/�`]�`� S��nnrure Appl� .nl or Agem � � . ��� \t _ ,111 0_ ._- " � . _ . _ _ ---;_?..i_,;--''- -=; �1. {' .�-s `t:c' , � 1 .. 1t � �. , r ,: .�.: ; ; , ,,,�, ,�. , _ ;_ .;_ - ;.-�, - ,. ,_, i`_ ' � �. � � � ;,o, . __ _ .�� , _ �:� - __ ��= -� - =: .� �� o . , . �,�� . . ..�� i . G G �� ` .< 1 , .� �p �. 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