HomeMy WebLinkAbout0794A l"JORKERS'COMPENSATION DECIARATION •j�
ins�rebora(celif[o,�eofVJorkes''Compe�sa�'onslnsu�anceF APPLICATION� FOR��BUILDING PERMIT ��
o�o certified topy thereof�Sec.3900,Lcb.C.) �
COUNTY OF LOS ANGELES . BUILDING AND SAFE7Y
P❑olicyNo. Company
Cerrified copy is hereby furnishr.d. FOR APPLICANT TO FILL IN ncovess L�C��=� � �%/ "�e�r;'>
� Cr.rtified copy is filed wi�h the coumy build�ng inspec- BUiIDihG �ii� � � �7 i `� QQ
fion depaHment. ADCRE55 i-t�_J:� �i /L/�� �� ,� l� IOGAtIiY� Q� r ) f�7/��
Dale Applicant CITY /J�f��7./'1 J n 21P ' �'� CROSS 5T.Y / � -+l��� �
CERTIFICATE OF EXEP:.PTION FROM WORKERS' NO.OF BtDGS. n5SE55CR
COMPENSATION INSURANCE 5�2E OF lOT NOW ON!OT MAP(ipCK PAGE PARCEL
This section need no�be com I�ted if the ermit is for one J �h u5e zChE nenr
hundred dollors(SI00)o�less.� P rRACT�—� '� BLocK LOT NO. � NO.
TEL 5F[CIAL
I c�rlify ihat in�hr,per(ormonce of�he work for which this �'f�FR �� � �,(L� NO��� '/�7 CCh�iliONS �
'i!- \ �f Di51RiC1 GROUP IYPE FIRE PROCESSED'i �
permi�is iss�ed,I shall no�employ,ony pr.rson in any mannrr , ��n i ^ I I ` ,� �„i
AD7RE55'Zi�i� ,F-!: �I�J `'�C�:�C � fCNS..
so as to bn ome subjr.ct�o the Workera'C mpensarion Lows. `7 � � ti r;
��] � / , �� �, .. V �s
Daie � • • �nppl�cnr6��l��/��� cirv LfP %' Z�� �� srnusncnian s�ricanoN AFT. CUN �
NOTICE/TO A PLICANT: If, of4/makin�thfs Certilicafe of ARCMITfCTCR �E�. ____ �)
ENGIhFFR h0. CLA55 NO. D':JELL.UNIT$_ �'-�
E+emption, you should become su6ject to the Workcrs' «
Compensation provisions oi the labor Code,yo�m�st forth• ADCRESS 5EY�fR fnP.N '-ni
wi�h tomply wiih such orovisions or this pormit shall 6e TEi .�
deemed revo4ed. CONTanCtOR NO. BK. PG, VAIIDATION
LICENSED CONTRACTORS OECIARATION uC, '
I h?reby c!firm:hat I am licensed under provisions af Chop�er 9 npCRE55 NO. VALUATION
(commencing wilh Secrion 7000�of Division 3 of ihe 8usiness and ���, ' O O O «7
Profr.ssions Code,and my license is in futl lorce and effect. CiTY [LASS S ,
50.FT. ti0.GF NO.CF CHECK
License Number Lic CI055 SIZE STCRIES FAMJlIES CN'
DESCRIPTIO^1 OF\VOPK 7 I N`W � S �
Conimctor Daie �
ADO
�I am ezempt under Sec. �
AITFR � FINAL
B.BP.C.for Ihis reoson ' � RfvaiR � DATE
Dafe: u5E OF FINAL....
FXISTING BLDG. �= � �`:•.OL ❑ g �
$i�nOfuiO
APPLICANT iEL. r I
OVdNER-BIIIIDER DECIARATION �FR!Nf NO. •
1 Mereby aFfirm�ho�I om e�emp�f�om the Conrractor's Licr.nee
Law for�he following reason(Section 7031.5,Business ond /DCQE55 � '
�079.4A
Pro�essions Cadn): Fk; ti
. OBl1RDING . �I� • • • � � .
I, as owner of Ihn preperty, or my e.mployees wilh qooa[55
wages as the.ir solc compr.nsa�ion,will do�he work and �p�t�TY � � • •,j�rj Q
Ihe s!rutfure is not intended or o(fered for sale(Section
7044,8vsiness and Prc�ess�ons Code�. MOVMG TFI. � ,
� I,ae owne�of the property,om e:clusivr.ly controcling f vTRaCfOe NO. • ^ ;;��,j��; _
with licensed cont�ac7ors�o conslruct Ihe project(Sec- qDDRE55 � ?�Q'�3
�ion 7044,Bueiness and Professions Code). '
PCCU!4F0 TOTAL SEI9ACK F4U•A E%ISf.
�ONSTRUCTION IENDMG AGENCY SEi CACK vnao Fivn FRO�.IM� wiorH � '
I hereby affirm�ha�there is a consfr�uion lending ogency for FRONi � � �
tha periormance of ihe work for which this permit is issued a.t.
tSec.3097,Civ.C.�. SiD:
P.L.
Lendei s Name ^ �r
� o
Lender's Address P.C.Fee 3 Permn F•r. L 'l
I certi(y tha�I havrt reod rhis applico�ion ond sta7e thot fhe. Iss�ance FPe 1
� �J �n
above informalion is torrett.I ot�rr,e fo comply wiih all Counly in.nr�goi�on Fee `�= 1'
ordinonces a�d Sta�e laws reloiing to building conshutrlan, To�al Fce —
�..and hereby authvrira represen�atives of Ihis Counly b eMer I�
upon tha obov;meniioned�property for inspeclion rpos s. �
��,,r����L��l�� �3O� SEE REVERSE FOR EXPLANATORY UNGUAGE , �� 1�
L/ S�g.1a'�re ol APPiicanl or Agen� Do� �
, `
2 -+
r m �+ (n t.�p C O (1�i q� n � T n � O I ' - O O
O � O O C fJ n O A � CL p O G p .
' S t7 j G' � O I i�� O n n n `r„ [) l" C7 �) '
� � �. � _ � �
� O `C � Ci i� U '` 1� L' L ._. C' C R = '(�
m � T 7 T J — (1 Il � (, �. ' 11
..7. N K N � �I C �- (1'] C T :
_1 7 G �� O C N (`� � i 6 ', �� C� '� _ L. � 11 P
O !:' O i- L n �: ( O i :y C C� -- 1
J U• (1 '.�
_ R U ��� �� � v O �,li f..� J M �O
� � 7 . i; _7 j .. — i0
1!_ � i �
� r � � �
✓' ' n �" _� � � w
�., , � __ ____. , t:
�� �
i ' j� j� o
�. —, � . ° ; i � �
i — -• a =
i ` I= �R �Io � a
I D .
� � M - � I 4 'd y
� �' I ., I
O - I
n
O � �
� . . v " � ° � �
� ��
i ,� , � ,� a
, ,_: � . - �
n o a v
� � • � <
, � ati e
a
' i .
`` . L '
. � .
� i
, 7_
' N
' ' . �
. Y1
n
. . �1
0
. � ' A
� ' N
� �� • U
� �_ - -,
�
• ! "+ . o+
V �� '.
' . .I.
I
� . . ' � .
, ' I I ' �= ^~ �i � .�� '`= '�= ^� ., $ � .. `- ^^-' � `''^ I- � ^`
° i,: ' ; .�� � ` F � .� ` � i, � ��, -'e'�: a
r, �l •`' c, c `' n ';:
_ '� C N �.�I c � � :f
� (; _ , _ .` _ —'_ �'• � ^ �� _ .., 'y [- � � . — .�'� � �� �^'i _ � w L f
i� _ �T `�, �l u +� ' �1_ �' �
I . . . _ , r� �% _ � '� v, � ` � "• _
p � ;��� r. n `. �`• ` �
s Y ': :, � -r :� �� � f
I � t; C � :. "' �i C `� �i %
. I ' I C.. ^ _ �_ ' -. � w v� ., } _ `..:> �, �,� ti
� 1 •- 'w _ ' �'•�..',: O � � -� ,� ^ N ' _ ^1 O,j ...
� I � I . . - . I , r ' � - ` � � . ' _ � i ^ , �' ' � �` ^ � - �, a C':
I ' . I � � �r I . ii _ %i � • j� s` : - . �- :._ :i - �•^,c:y"�a � ' ci__ � .
I 'I i I I ri � i �� � _ ,; � ., `._ .^';' r� L o ` � �,; _ � _ c r
I I II f • � p I . r^ �� V _ ;_ '` � ii�� � i� — . B.`;� �� •. , ;` ' � —
.I i �i: � ` r •c � �r ti V- '�7 � � .�•:��� �� 7 �
i I I I I , . , ` � f, y ` _ _ = .A^.� � : •t..�^ � � ^ 1 ~ � � ^1.�
. I I ~ ',- � _ ., ' _ ' ^ ��� = n $'= �r�1 1 � " _ C� ^�� " �' r
I � ' ' ' ' � '.-� r,i ` ^;::"1 ~ y , -� ` _ Y .. F �' '. ` � [� ' `
I � N C. , . n . . 4 ,� � �.'�` � _ - �
i ``1�a� u ��`�� o Y � C' f � ` 4�� � , , r. n
C � " 1 y • � L L �• � L �'� J
�� N ^ � , � ��-.\L. �i.. ' ., G �= .:_ w �-:i: C,.-� ,. fl %
I � I r J (,,(` n �{ ti`N�(/� j Q 1� V�•� `f+ Q � � �'
' . (1 •�'1� '• n " ^- "� D n � �' u .^^. ��'` .�L � v "
' � • � L. n N r". �•N �� ti'• `^. ',�; � O C
' i � .� i .. � ^ � ,: e �': t��, � C„ �i � ` n� r. � �.+n
o� • _ � `,.. o n f �. .. c';.^o z. o
, - " e � � n �c� , c�� i: � = � �°'�y � .. .. .�''`^�� �
. . v : .. . .. � � i . .` . i , �_ � . n