HomeMy WebLinkAbout1279A 1280A � : _. s
WORKERS'COMPENSATION DECIARATiON � ,, . -� . ,.�_� . �-
1 hereb irm t I hove.o.cerhficate.of�o�se�,� �r� pp�;��CATIQN� FQR BUILDING PERMIT �
insure r a rtifi ate of Workers Companaation In rance,
or a rtifie copy ha�eof t5ec.3BOU;Lob.C:) . . . .. _..._ ..
" ' - COUNTY OF LOS ANGELES� BUtIDING.AND SAFETY
Pol"YNo. Company�.,. . .. .
r ' d c y is.,heroby fornisFwd, - FOR APPLICANT TO FI1L 1N �1����NG —
ADDRESS
rt fi d opy is filed wifh the munry building inspeo- BUILDING
' t n enf. � .. � AO�R � (�`C .
. . _. ... ..._._. ... . ... ._.... . . � .. .
e Applicant CITY UP LOCALITY
�� � CERTIFftA7E F EXEMPiION FROM WORKERS' .. ....._. ..�.�.... .._-... .NO.OF�atoGS. NEAREST._... ..........._ . . ._._.�... . .
� � � � -{O PENSATION(NSURANCE��' � � � 511E aF LOi NOW pN LOi CRp55 Si.
(Lk" sec�ion ne nW be cnmpleted'k the permit is fq mna . . .... .. ." '..... ..... ..-... . ---. A556 R� ..
�6utldr doll j=)00)Or Ieu..). . . . T�R BLOCK LOT NO. /y�qp , . . ._�... PAGE PARCFI
i certify fhat ia the pedormance of the work for whic6 this OW�� C � �" N07 7"f3� � � .
permif ia issued,I sholl not employ ony perwn in any mpnner � .. . ~ T
ADDRE55 �... G _'_.... _._-�_�� . (�"� O
cu os�c 6ecoma sabject m the Warke.s'Corr�penxnion[aws. -- COMDmoNS J ..
� �
Dore � � � Appl�cam.. . .... ...� ; ��. .aTv�l'✓� z�P _ .. Q .. .. ._ . : �. . ... . � .�
f• NOTICE TO APP�ICANT If-nf4er makmg tb s Cemficate of ARCHI7EQ TEt� ..(}I57RIC�_... GROUP tYPE FIRE PRO(',E gy O
p emphon -you-should become wbject fo tMe Warkcv� � - ��NEER� �^ � NO.!('���� �� � G
`.. .omp9nsobon prov�sions of the Lo6or Code,you musc forth- pppRESS w
v�ith com 1 - " '" .. � . . - .._. .
p y.with such provisions.or Ihis.permit shaU be �-� � --.___ _ -_._ _y
doemed oevoked. , Trio. srnnsrrcx�c F �N � nvT. conroo. 7:
CONTRACfOR �
� LICENSED CONTRACTORS DECLARATION -- � LIC. �u N�• �'DWEtI.UNiTS �
1 hweby.offirm thal l am licensed under provisions of Chapter 9 ADWtE55 r.p,
(commencing wilb Section 700pj of pivision 3 of.the Busi�ress and .. ......... . _ ._ LIC. �WER fMP . . .
Rofessions Code,ond my license is in full force and effett ��iy - ��q� � Y����� � ��
.:,�.. ... .. . . . . . ... .. . � BK. PG. �
. .. .... ... . ._ SQ.F7. ... . ...NO.OF.. __.... NO.OF . ..CHECK,.. .
�iCanse.Number.... ...... -� Lit.Class . . . � � 52E STORIES FAMIUES "_.._..,._ �E . . : .
.� . . .. . . . . .. . .,-' DESCRIPTIONOFWORK _.._. _ .-...�—. . NEW ' ._V . . . ,'�.
_ _
ALUATION.. .
conencrar oata qpp � s(��j;�: a 1 2 7.9 A
p �cX{�✓t ' J� �n
�I am exem t under$gc. ALTER.....� . �. . .#�.• • �2� . .
B.BP.C.for fhis reoson - REP,4�R- "-_ ;�n N
,. .. .___ . Date: u5E OF -� . . . . � ! �,� G.�
EXISTING BLDG. �MOI '� - � .
Siarwture �-���lr� AVRICANT . � 7EL F{NAL'"-� - • 1.I Y�;;:?l,'_
NER-BUILDER DE ARATION PRINT V 1�t n10. .. . . . .- +.
1 hereby 4#irm thnt.l am exampt frbm tl�Loryroc�or's License � � �ry,," DATE. . . .-
Law(or the following reawn(Saciion 7037.5,�Business and ADDRE55-77 7� (�C`J. d�t.�'i�.t._.:,1� ��l� - - . -.. . . . f G 2 2"i'6.......
� FINAL,�... ... ....... _. ,. .
-P�ofesaions'Code):-. . _� ..._.. _. ...._ � _ . _ .gy . .._ .. �� ��x�� .
' � 1, as owner of fhe propeny, or my employees with BUTADL�DIE� � � , �
'� �� � • • �� .
� woges as iheir sole companwtion,wi11 do the work and �� �
-� �he struclure ia not intended or offared for sale(Section ����T� . j � y^�9 c�^,
704d,Busineu ond Rofeasions Code).� � � � MOVING� iEt. � � �
� I,as owner of the properry,am exclusively contracting �TR'°'R� �� ^ __ _._ •�r9.�J-G.J�c=..
, .....
--witkikensed tontrocrors ro consfruct the project(Sac- aDORE55 .. .� � . ...--� .�. �%Y .-�- ` .
tion 7p44,Busiaess and Professions Code�. ' � �2 2 2_v�5 -
� .REqUIRED 7DIAl5E
CONSTRURION LENDING AGENCY � - �T gq�K YaRD Hwv pRpp,uNE WIDTH ' �
I hereby affirm that there is a construction lending ogenry for p�7 - ' .
�-the performance of the work for which this permit Is issued p,�, . " � - � � � �
(Sec.3097.Civ.C.). SIDE � � � � -
m ... —..... . .. . . ..... V.L . � .." - .
Lender's Nome � - � - � � - �
IDMA Ref.N . .
m tender'sAddress ��- P•GF°°� - Permitfee � - '
k .i tMify thot 1 twve raad lhis opplicotion and stale Ihal 1he ..� Issoance Fee IDMH P/C M . ..
� obove information is correct.I agrea�o comply with all County .
� . ordinonces p�State lawp relating l0 6uilding tonstryction, . � �• T��� • � �
� tDMA perm.k ��
�.
Y'i qnd hereby outhoriza representatives of this Co�ny lo enter - � � �
� upon he o6ove-m r ioned properly for inspecfion purposes. .q �`� .
a -� .. . . . C� / - _ ._. � .
,������/ Q --.. _---..
� •W�(M� I��I Y'a� SEE REV OR EX�LANATOiY IANGUAGE �
........ Sigmaure ot Imnf or Agem Dots � - � �7S� - �. • . -�i
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