HomeMy WebLinkAboutNo Permit Number (3) 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� •
�
%- o
0
��� �.
. � :
� '� � c
^T o ; �
� a o
� nv �n- `- `� � ✓ � ' r
o �, o o a o
Q � 7 n, y:� 4't � v0 ,�r,J' '^ Z�'. Q
x• O n Q � !; a � C :�i
r". � 0 :�-` 4 O 3 n c
N q �f�.'�� SS 7 �a p� r' ? 'ry L� . +p
r„ '^ p c -�-�U : p ',^.� � 'o ► �c , • r
� � a er � U fi' y u ° a <, o � p
... (�S � ` `� 3 / o F7 v � ct n ✓� � Z
r. ? � v�
�C �� ;i �o � ��o � � � ` �� o �
-� ' �,f7 % !',,,,C 7 ��-" P �ar,. � � ' 'p �
7 Lo�� f� .O p �' �' it�-„ P� .�. y�U
-^ -c 3 � ° G: .t -;� . ° �
p O tF ' O ;7 D �p � C •
� �:r. 7 • � r s, �'
i:-1 (� � �• �1�� �fi i..
.�'�� O �.r'. fr rl
✓ ,' G G� }C
' Q O
�t O
r � '
�• �
�
� ' o� � ' �, y
/ ! � ro �
: ; �m �
: � y i �
op � o
/ L', � e� ; a
� � G�
' ��� w . . 6
r
Ly
P
� C
� �
�
f
. �
S
. a
� A
. • N
. � •f' 0
�
, � N
,� ,.. r,,r
�y a N n T
�
� t��� U �C �� F.3 �l�
y � [. ' �
C �.N..f rJ .+�L^G'}� �`;r!y �"t~.'�"J t' N N '.�Q/�
v L.-' = M• H N 17 u � �C O 1n r. .s �P �p�T,
e-K n c a ^ �� a � �:�,� �,o t-�.F a M ^_-7.
�y �M' A� rl� �� � " x ° N c p +� ^ ,,,, n ' M N ., ` j ..-
C .p. ." ..s"i£ � _ 3�0...' n �� M p; t sv � :•`=•« v.c� :'�.� �r
a o � shN..M _� o �? a �.�n��i.,� O,� �=•.: MC� ^N ^ '^ T� G
N � �S� H`-�•C ': N � 'u� � O „N � ' � C '^ Q �•
G a � ^ � � G O O C•`C,� C b��p '-. .a.�� y O e' H L'n « o O 7 C�
� a N,..._ = v, 7 � �`r:. «.c• � e' � �r:. ^ c ^`� ''' =2 � C��`��` � Cl �
�.� �^ � � ' o v� . � 1 w � � «.: o a .-�
% t c` NYu'� �o" � x°•:Qc �� 3e G ::r�^o,-`� '= � �,�.�,r'.,' �'`'�"' -,�-.t
' - ..., "
,� 3 N � :� x �?�`-4- oc M.'��w f1c-7 o e�.° ''�'y � " ° �+`av n
• � � ;� �c � n n t�C:.�n � � i..� q o ._�^, G'1��'n�.':�.�"' N "':+
i C. ii n""'�'Y N�9 0. C��N O" � O O � � N : C H�'O i; ��" „_'h'•p a �
N ;� � o °'i�.°� o c..F. C t--� F'� "+o �{ �. " ' a ? � � "" ? ..?
m U' `�`' o z 'o ^ w� � c� M�,� r. f ° ' �' V+p „ ? x' �-. � S•►
a n
n n `-� c r n� o �` ' ° 'a f1°'s 3 �'� ��-[. = C�::S O � �, O
�'' -�-r n° n c " &.,s::n c ° o a'< c"-,� .e�a r.« �. a n � � a��
� � � O C N � X i�^``,ea C'.J .. O A C''O e� t"Y p ti-'„' �.' �
' �: N �y s^_.� � ,.•�. G-' s"F. : i. %y 3 N 4 ` �""yy�`"=� ^`r U a.
� * �„�t � ^ 9 »-.r F'n � �, r, � o�
Z t`� �' � � C � � �4 T."� C i-p � GW i^ t+wi q y r �,..L' i U
O � � C~+'=��� '� �.C..`'^ Z -t N�L N C �-�•�n �L-- - ..
N O - 1 ��� � J V....�..� � =O M�� F N Op �� y^p ^�. C�_.tN.u�
ti
� m c `.; o �o -.c �s cF �� xnoo4-`r-v ,�', '^ � ..
�^ v � � " � n o r r1a ?? ..:."'N y�3.�"' ...
:.�ti L^ .. � o c 3 c L�r,...
n 't t'' �' �+.C+` �.i �
� � �- C C � ti C r _
n` c �.� � '.
T ��� �•
'u�
r