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HomeMy WebLinkAbout1746A (10) . • �, WORKERS'CO'J!FENSATION DFCLARAiION ... ........ .. . . .. _ . . . ... . . . . . � ' I � " APPLICATION FOR �I'�DINC PERMIT � ` .1 hereby afiirri thot I have a,cenHfco�e of consem to se�f_ . ..._ _...... � � .im��e;or o ter�llica!e o�Wo�ke+i Compensii�n Insurance,cr a ce�rr�ad copy rhereof(sec.3800,tob.C.). ., COUNTV OF l05 ANGELES- BUILDING AND SAFETY Pplity No. Company �.� BWLC:NG � � a� Certiliad copy is hereby furnlahed:� �� - -� � FOR APPLICANT TO FIIL IN !•^DRE55 ��S •.�"��-�"��L � ' � nCenified copy�s Cled wi!h the ccuniy building inspec- BU'IDING � t _ � 1 !� ��on depa�irner+r. ' � ' ' a�oaE55' S C �MA LOCALITV `+li^..-��1 47rr �.� �• �. • �, . . . .. � NEARfST ` �• 7 1 . . . .�Do�e � � Applimm ' -� - Ciiv� WiV� - ��2�v � Crt05557 CsJi�;, ,�7 ' ��� CERTIFICATE OF EXEMPiION FROM WORKERS' � NO.OF BLDGS. ' A��+' ' �•� � '� " COM�ENSATION INSURANCf � � �� � SIZE OF LOT . .. . NpW pN lpT . MAY PAGE PARCEL I � �(Thii seciion'need no�be�romp9e�Gd if the pMmif is fp one 1RACi.3� /.� BLp[K LOT NO � U�� / . �P r�-(i-„���s' � hundred dollars(5�00)a lect.l • � �i SpECin� „ y I I cert�fy�fwl�n the periormonce of�he work(or.wnich�his.,_ _ O'r.'NER �f� ►r' NO ��0��� f01'�1ilON5 Q permit�5 issued,I sholl nol employ any pprson in any manner qppRE55 � �C���� 7�- D!STkKi GROUo Cv�'r FZ� GR')OCESSF.D BY � ' so os�o become su6ject to Ihe Wev�k�n'Com� nwtion Laws. . .V� �� �3 % -��- �f � . - ( i � I! V acal�/ � • " � .. �'• / CITY�\��Y�� ' 9aie � RpPlicanl �� �- • .� Z'P S7AflSi!CAlCLA551HCAl�ON � AVT. CONDO. W 'NOTICE TO A ICANT: If, efre��maling el+�s Cen icMe of- .. . ''��U�i� ' -'-'. ... ..- . . i�..... - �� .. _. � �f�emp+ion,�yo� ahoub become aubjet� b �he Workers' �+INEER �� CLASS NO�DWELL.UNtt$ y ' Compr�sn��on p.p.��s:ons of tha IaMr Codr,You+nust forth- ' ���� . . . . . . . . S�Wxo MAn Z , .wi�h wmply w:�h sueh prov�rona or thia permit shall be , . deemed reuoked. � . . , . ... . �OMRACiqt K] iEL. .� �. �. YALIDATION - LKfNSED fONIRAGLQRS.,JD�EGIARATION '/��{,�'., ir[.. • . I heraby nH�rm thot I am IICMSld V.ryc1{�lOY�LQS�S O��+.ypllf G. ' AOURt,1S .S'�S . {�Nl�,`' - NO ' � � V VAlUAT10N � � ,(commr.ncing w�th SecGon 7W0)o�Diwslon 3 of ihn Buainesy ond �K. . � , Aofessiom CoQe,and my I:�nse is�n iull force and effec�. ,,, , � 7V ' C�'2 f !7 P � , yn Fl NO.p NO.O� CMECK � :�}tcaMe�Numbe.��__Lic.Cfoss�T_�� � �� Z�� SiOrtRs vauu�ES ,�^ i , J ��� � NFW �. f I ��ConrraUor��MAR#.S� ..- �(s�.n..�e 5/1"/iT'L .. OESCR�Pi1ON OF WORK . ,.. . ❑ � . � ' I am eRbmP�i�m�rhe li 'roi u q �r�� . >>iCT •L�A� A� / ��❑ ,tC o8ce yireman�j 03�am o � Si . . . Ilcensed ar�iieci or a reB�s�a�ed professional ertginRr, ... . . . .. .. . . AIiFR � FlNAI /� .� �ad'yg in �`y profest�CFa� coDaS�t.Y (Seclion 7Q51. ' REauR O DATE �� � � � B�sinesf ond RO�ssiona Code). �� !"I FINAI . j &OG. l.] gY ,'1, Lic or Reg.No.��_Oa�e���. � . . .. lEl . . r� �,•,.(,n ; . _ . owra�e-�cmoee o�einan„oro�- � - �n — 3 6 /h( �(j(� ' I hereby a�f�rm+Iw�I cm e.empi from rhe Co�hocror's l�ce�e � � lS/Oa , `6� '` �('��`��J:... • . •,� � 1ow for rha Fo.Uawiag�easnn(�euion 7�p(i�.5.8�si4ess o�d r Rofessions Cada}� � . A a t IF_ , ff��eZ�W� � � • �j.',�,;j ' ..fl �1, as owner oi ifie�P�aPe�Y. cx my�emp�oyEes w��h-. ' .f�DPREDS�S -. . . � � ^ __ _ I woges as�heir soie compensaaon.wJl do�he+.w4 ond . �-�.�-'� `':: !.-',�; . .- . . rhe orucr6*e y�o�imended o�offSredfor svle(SettiOn �A`' , . � � ' . . 7044,B�tinefs o�Raiesaions Coda). iEt. Q:i.�.��-�G .. I,os owner o4 the properry,om eRclvyirely cprnrvc�mg �� � � ' �� w��h licansed connanon io mnatruc��he Pojan(Sec- .. . � . _ .... �w��7W�k 8u��nen ond?rofs�siom Codei � - a �u .- . . � CONSTRUCl,�MV IENDING AGENCY . �,Bpa yqRp f�wr TOTA���IVHAC�FROM W fH , �I hereby oifvm�ha ihero n-a construcnon lend.�ugeeqY fa ' FR(YJ�' ... . . . ihe pe�formonce oi r6e woh for which rhig perm�i�s�ssued v t • � e _ ISec.'3097.Civ.C.). . . .. . . . ._._ � . . . . . . . P�i. Lender's Name _ . . . . . .. . . .. ,... � . .. . . . � , ' P E.Fee S iPrmii F�. ,:Z�. � , Lender's Addrass , _ . . .. . . . . �� I ce.Gfy rha�I haae read rhis applicallon and s+o�e rho�rhe issua��e Fae p-s� � • , } i � above iaformp�pn�s mrrqtl.1 agree lo comply wilh OII COun!Y�. .. � .. . . . . . . . .- - � � ordlnonces and SW�e laws reln�i�g�o bu�ld�nq co�strucfion, Tr.��l F� ✓'f• SQ . . . ', � 6nd hereby a hori:e represen�a��.en oF thls Coun!y Io en�er .. . . . .. . . . .. � ' y�eTM�g a v .men�ie�'$roD�M.!Y Sor inipe�rion purposes. �. . , � , < ' � ' � �• �' ' ' � � SEE REYERSE FOR EX►IAHATORY L UAGE 4p�o�ure o�App��roM � � ro • . . • ' ' � . _.. .�. .., .. . �_ ..AN6 . . .... .. . . . . . . . . . . . , I �. . . .... . . . .. . , _. . . .. . . ._. . . . ,_.... � � �•'�� `'�1 , . ,M � _ o •• ' ' ..- _ - ` ` -.; , ;. _ , � �. � ,',`; ` .�` • , � �;,�, . . - �-�+ � �'j\a -• "�, :' , _ u+ �:' �� - � 'O ? i; ��o � .. ' � i C.'e7 ".'.N L�. O T t� •+ � (f> ;1 !� � -. � � C d �� � � U i)�� �` � � p G '� 1 , t _.% �-� r� � ? '� �;, y � j .s C .� �, _\'. �' ; (,�� ,n �� p � O ,ti �� C•'•M G �, ' \. ' ��/y. l n n O �,. � � p =�� �t C: � ` ' r G �^ � ` L' �� 7 � ti p 'i�' . . . . ��� ,�.2 Q . ,,,� ('1 S n � �1 O � � � �\ C .ti� j . ,� ` o K � �" c.'^. C T � C '� • v, 'C c � :\ � �• ?,L •��`i'� �n �.c � _ C r c9 1 ;t , _ � w ` a� �? 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