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
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