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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 � ........ 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