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HomeMy WebLinkAboutNo Permit Number 1'lO4KER5'C0:4"�FENSATION DEC�ltRATION II I here6y nf(irm that I havc a certificote C(cOnsenl 10 5e�, APPLICATION FOR BUILDING PERMIT '� insure,cr a cerlificale cf VJerkers'Compensiion Insurance,or a ce�rlied copy thr.reo��Sec.3600,�e6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Compony ❑ Y FOR APPLICANT TO FILL IN ACJDESS �I / �' G'� Cenilied ccpy is hereb (�rn�shed. � Cerfilied topy is��led with the coun�y buildinq insp�c- ^UILO:NG �^ µ� licn deperimem. AD�4E55 � !f/ (/'/ IOCALIN r �;FARCST ' Datc Applicanl CITV �j/l��/� ZI� CRO55 ST. 'V'��f Q. CERTIFICnTE OF EXEIAPTION FROM 1VORKERS' NO.C'CLDGS. A55'SSC2 COMPENSATION INSURANCE SIZE OF LpT NOV!CN LOT f IAAP GOOC PAGE PARCEL (This sec�ion need no1 be complered if the�ermit is for onc USE ZCrvE �.+nN r raacT Z t� / ocK �oT no. ho ' � — '� 3 hundred dollnrs(S100)ar less.) } TEL �/ qq 5�'EGAL d O'liNER � NO�'7�/I � CCNDITICNS I ceriify ihot in�hr.performance o(�he work fo�which Ihis � permit is iswed,I sholl no1 employ ony pe�sOn in any monner D�S�RiU G.OUP iYVE NRE PROCESSFO BY so as to b�come subject lo Ihe N/crkers'Compenso+icn Laws. �cee�ss � 2 CO�'�y�� Z04E � Do�e APplicanf CITY Z17 $IA�ICAL C1A551F CAiION '� API. COnDO. O NOIICE TO AFPIICANT: If, oirer mnking this Cerfi(icnle of ARCHIiFCTCR TEI. �y E.empi�on, you should 6ecome sublP�� �o the VJorkers' ENGiKFFR W NO. CLA55 NO. DwELL.UniiS o. H Compensation p�ovisions ef the Labor Code,you must ior�h- „G^:Ei; st•.•rEK�.+.ap � wilh comp�y w'Ih such pro�isions or this permil shall bc J TE� — deemed rr.voked. VALIDATION CO!JTRA�TCR /1/Y'J NO. eK. K',' IICENSED COYTRACTORS DECLARATIOY UC. � I hcrwby alf�rm+hai I am licnnsed under provisions of Choprr.r 9 ACD�E55 ti0. VALUATION (commencing with Sr.c�ion 7000�of Division 3 0l the 9usiness and LiC. Professlons Cede,and my Ilcensr,is in Full force and eilecl. Ciiv CLA55 5 5(l.F n(f '�O.CF NO.Of C�'ECK � License Numbe.r Lic Class Si7E G� . STC41E5 j FA�e!LIES O�F f�RN 5 ConlrOGlOr DO�e DFSCRIPTICN CF YJO4K ❑ _r�,�,�', ❑ AC'� � ... t,: .. 1 am e.empi from ihe licensing requirements cs I om a /O � �,� � ���� 'licensed erchiiect or a regis�ered prefessianal engineer „ /LTER � FINAL y� � ocfing in my professienal cepo:ily (Se�tion 7051, R� DATE . .DA!4 � �y, ,r, B�siness o�d PrcFess�one Code). uSE C� G� C=:'.OL FINAL ��� ����r Ex15iINGBIDG. /�')G.. ❑ BY _ Lic.or Reg.No. Doic nF.LiCAVT TEI. ' ' `� ' . � O\VNER-OUILD'_R CEClA2ATICN �����T� ��' I here6y affirm iha�I om e�empr f�om ehc Con+raaor's l�cense � . law for ihe foltowing reoson(Seuion 70�1.5,�usiness end pCD�E55 Prcfessio�s Cede): i5tv; . � . . . 3UILD'Ir'3 � , .-:i _C: I, os owner of Ihr properry, or my empl0yer.s with ACD5F55 woges as!heir scle ccmpensr.tion,will do ihe work ond �p�ALITY � the etruc�ure is not intended o�o1lered for sole�Seciicn 704d,6usine!s ond Profrssions Code). h�OVING TEI. � � I,os owner of the�rOperly,am e�clusively co�lraclin� �ONT4ACTO4 NO. � � with lice,nsed centroc�ors lo mns�ruct ihe p�oject(Sec- qCC.E55 . rion 70=a.8us�ness and Pro(r.ss�ons Code�. CONSTRUCTION IENDING.4GFNCY ftEUUi:FU yn�D HVfY TOfAI SEIfiACK FRO'A ExIST. ' SEI P.ACK GPCP IIN� 1VID7H I hereby affirm ihot there is a convrudian Iending o,ency for FkUNi ihe perfo�monce ol the work for which this perm�t is issurtd v L � (Sec.3097,Civ.C.). sioe v,i. \ lender's Name Lender's Address P.C.fes 5 Pcrmil Fne � I ce�iify thot I have reod fh�s applicntion and staie ihat thr. iss� rn ven �� � ebove In(ormotlon is conecl.I nqree�o comply with nll County �,,,,ps„�a,,o�Fee n� �'7' �- �rd��onces or+d Sroie la��s r=lai�ng io b�ildinq construc��o�, ic�ai Frc �/• S � and hereby au�hcri:e rr.prnsr.niaiives of th�s Coun+y io eni�r upon ih obo•�-n .ntionr,d p•�erw -._sp=U�on urposes. � � � SFE REVERSE FOR EXPLANATORY IANGUAGE $�Uno�.re 'AFF��conl o p•nt •��/� �� q� Gf�iJ /.� � �e� • -_�+ n= m -n N �n t N ^r � � T = �' � -1 ' � () (] C l O O � f n . 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