HomeMy WebLinkAbout0930A 0931A - !
WORKERS'COMPENSATION DECtARATfON �
I herebq affirm that I haye o certificate of conseM to self qpp��CAT10N FOR BUILDING PERMIT �
insuie,or a certificate of Workers'Compensation Insuronce,
�or o car�ified copy thereof(Set.38�0,Lo6.C.y ��• � �� � -" - .
� COUNTY OF LOS ANGELES 6UILDING AND SAPETY
Policy No�f 3_�7.ComPany�'i}[/�f/f�19T�Gi.S� � .
� Ca�t�fied mpy+s hareby i�mished: FOR APPUCANT TO FILL IN BWIWNG � (J
�� / ADDRE55 ,� �S�
�Cadified to 's flled wilh the coun 6uildin ms eo- , . �----
py� �Y 9� P BUILDING 7 / p
tipn eparl ent.� '� . .. . ADDRE55 �} (JDU � i�(�
Dale b .� � appliconr (d cin / D • zir 7/ S � �prp,��r�
CgRTI C111E OF EXEMPflO FROM WORKERS' - SiZE Oc�AT ��6�J�XJIS� NOW ON LOis C�5T.
� ' � fOMPEfd5AT1pN I SURANCE
�This aec�ion need not ba comple�ed if Ihe permi�is fw one � q � - - -�� - �R ' __ �
hun�red dollqr4($70p)or le5s.) . - . � TRAQ d l 3 BLOCK lOT NO. ' Mp,P BOOK-� PAGE PAR�I
- TEL USE ZOIXVE. M47 .. . .-
I certify that in the performanca-of the work for wFich this OwNEa e pp. - � � � �
ermil is issued,I shail not em lo�an rson in on manner / �p 1� �(/ � � SFEC�AI
sPo as to 6ecome subjeclla the Workers'�Compensotion Lows. A�RESS (3 � �lf (.�U{1� (//(�� � CpNDiT10N5 �
Dara " ' App�icant . ,, ... arr L/1 0 ��' ZiP � p...� � pC
NOTICF TO APPIICANT: if, oker making fhis Gertificata of ARCHIiECT OR TEL. �ISTRICT G20UP NPE FIRE PROCFSSED BY O
N INEER NO. [pryST - ZO� V
Eaemption, you should �become wbject ro the Workers' /[��
I Compenso�ion provisions of the tabor Code,you must forih- qppRE55 �� � � d
wi�h comply with such provisions or this permit siw.Il be - --� � - �� /� � y y
I deemad�evokad. � � � - CONTRAROR � P P{t •LO NO. 6 -OpI ; STAT1571CAL QASSIFICATION . APT. GIXJDD. .L
I LlCEN5E0 CONTRACTORS DECIARATION �� �i�, �(�y CLHSS i�.�DWEtt�tiNiTS
• 1 here6y offirm thot 1 om licensed under provisions of Chapter 9 ADDRESS �f�d iY, /�' t�-9 Np.��T/o�
�commerrcing witA Section 7000)of�ivision 3 of the Business and /� l�. SEWER MAV _ _ �� .
� Prnfessions Code,ard my license is in.fuli Eorce and eRect. CiT�' L��✓/�� �'�'6� . VAi1DA7{ON
I ... __ . Q _ ��i 5�.Ff. NO.OF NO.OF _ __CHECK �. PG.
License Nymber���-��4� Lia Clcss•� �'��� 512E STORIES FAMIt�ES ONE
,/ �/'//�y� _YALVA710N
co�macror � ��°x$ •��Date"7�T DESCRIPf10N OF WOf2K "FW � t ���p.�
� ❑1 am exempf under Sec. i it/ �'J^/��O , DY. p`�. � � �0 9 3.0 A
ALiEN �
8.8P.C.for this reoson ��R D . s - �• • • •'Z�
Date: EX STING BIDG. � ❑ - I • �� �I�.S O �
SignWure . �.� . .... . � .. � AVRICANT TEL. � FINAL = .
OWNER-BUILDER DECtARAitON PR�Nr , . No. p __�f r7 / _ _ • • •� Z S O o
1 her aff'nm fhot 4 om exe t&om tba Comractor's Licanse / `/ p /7 ' -f ra -Q S�---
Law�the following reasor��5ectina 7031.5,Business and AODREu �r��'+ .'V[ �1.,t-!��'`A�n�"`f (--D✓���' Flruu � 0�b c 4�8 Jr
Protessions code)' . ". � - .-" . . ..--Br-� ��� s 0 9 3,1 A
� 1, as owner of the property, or my empbyees with Ba�� �` �� �\ _ � � .
wages as their so�e compensation,will do the work and }� �-�M
rhe structure is not intended or offered for sole(Section f�
.._ LOCALITV ... �• • � • • �
� 7f1d4:Business and Professrons Code).. .- .....__. . Mrnnr�...... ...� ._. .. .. T�.----..... ._ .. . �S I �
� i,as Owner of fhe prop�y,om extlusivefy co��raCting CONTRACTOR NO. � � �3��5��
-with ticensed rnnhattors to ronstrutF Tha-pro�ed�(Seo- . . AooREu �-- --. ... - --_.. . . . ._ _ .. •�(�%5�
rion 7014,Business and Professiona Code�.
..._ .REOUIRED _ OTAL SESBACK
���LONSTRUCfTON LEF1D(NG�AGENCV'.. _.-_ . �7 gqeK YARD "HWY � pppp.LINE �WIDTM D�L 4-E3 S
I hereby affirm that there is a consvuction lending agency for FROPIr
Ihe performance of ihe work for which thn permi�is issued p.l. � � �
(SeC.3097.Civ.C�. SIDE � � � � � __�--�
.. . ._. .. . -._ _ _
v.i.
lender's Name '
��� IDMA Ref.M
Lendar i Addreu-'-----�--- - - --- - - e.C.Fee i - �- vermir Fee - - ...----- ._ ' .
1 certify.thatl have read this applimtion and.afole ihot.lhe iasuance Fee IDMA P/C N
above information ia correct.I ogree fo comply with all County i��es��y�w�Fea � �
ordinancea and Srote laws.relnting to 6uilding wnstruction, _ _ . . Teal Pee - -�- LDAAP.Perm.N- ��
and hereby authorize representatives of this Counly to enter
�pon e obove-men/t/i9Jj�ad pro e/r�y fw inspecti n urpo s.
.. �(�f'� `�CQ,.�. . ����� SEE(tEVFiSf fOR El(P(ANATORY LANGUAGE
.. .Sign „�.oFR IiJ mm urA�-.._._______-_.�s- . .._ .._. � /
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