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HomeMy WebLinkAbout0794A (4) 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� � , ` - x � 0 0 �.�- _. � � T � Q 1. . ,� � � G Q. t) S� r r,c� �a � tl. � 7. .n ... ti .o o �n � � o � ..C� c „ ,'O C n J� G C; �; = C� r � C7 ii L t1 G ' 4.' n L� O -n 4�O 7 C � Cl'S � [ 7 U � • ^ �n o r�U' � � �N c� ,i �, ' 1 s � m p � r t�p '` �. c"� ii c � �.; M 9 7 ° Y r �� `,t�� . , � C7 Y'� y1 j .1,. {,: � �n � 3 p>1 � � �� " �; . 1 ;,w '' � �i N N ^ 1: �M ; ' `_ 11 C O �/ :'C' C; G O � p; I� tD � - . 1• �y � .. ❑ �s F: O- -•� „� N�:' ° 1 � i: ; �o � , � = C,..� J '1�—_ ��� , 1.M �°• �Q D h � • �� � •4 ..1 ,I ` • x n i c � '° 1 - �— �' 1 .. ' � � 1 . 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