HomeMy WebLinkAbout1656A VlORKERS'CO:AFENSATION DECIARAT10N L �
� insureboro'ccril(�a1�cofVVorkes''Com�pensano���=��o��` � APPLICATION FOR BUILDING PERMIT U
o.o cer�ified copy thereol�Sec.3800,�ab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. Company B:liIDiNG
� Cert+fiod copy is hereby iurnished. FOR APPLICANT TO FILL IN ap��:u ��p�p S '�S q;�
� Certilied copy is filed with ihn couniy huilding inspec- BU4D�NG
tion departmont. nDD�E55 � -a � '� � i
Date Applimnt aTv ) /✓ /� i�� /��� IOCqUTv �\ �0.+ QV��
CERTIFICATE OF EXEMPTION FkOM WORKERS' NO.OF B:DGS. hEA�EST _
COh5PEN5A71pN INSURANCE SiZE Oc lOi NO'vV 04 lOT CROSS ST. ,a�
(ihis eec��on nead not be tompleied if the permii is for one ASSESSCR
hundred dollors(SI00)o�lass.� T2Ae* e:occ �oi h0. erav BOdc PAGE PA4CFl
�/� /� �/� �i�C�4',o � uxzor.: �o l O �'f'
I cartify ihat in the performan:e of the work for which Ihii O�.vr.Ez '
permit is issued,I�hall noi employ any person in any manner ADD4i55 � �� ��G^' �/��/ � ���A� �
C04�ITION$
so as�o becoma wbjecr to ina Wprkers'Comppnfalion lawf� U
Dara ApPlican� .�.� ��,� Di�l��zr� .�,e =��9/7-, �
NOTICE i0 APPIICANT: If, aI� r akin t is Cerlificots o1 AR[MiTECT OR TE�• DiSiRKT GROUP ttPE fIRE vROC:5:.7 DY O
EhG�k:ii Nn CO�.S 20h: ` F-
Eaempiion, you should become su6ject to Ihs Wcrkari �f' � � �n �(�(1\\�� V
Compensation provisiona of the Lcbor Coda,you must fortFl- pDDRE55 v '� �� ��Vl a
wilh comply with such prorisions o� this parmil shall ba �^ 1EL.�t cJ� STATISTICAI CULSSIFICATiON P.PT. CAN,�O. cn
daemad revoked. [cVTRACrCR �7 r� h0 ! �/� Z
IICENSED CONTRACTORS DiCLARATION uC. r Cu55�O.�DK'ELL.UhiiS
I hereby offum�ha�1 am licensod under provisions of Choptar 9 a�DRE55 ��i n0 7 7i�.�+ ����P
(commencing with Sect�on 7000)of Dirision 3 of ihe Business and /1,5 LiC.
Prafessicns Cede,cnd ny licenso is in full(orco ond aHect. ciiv � C 5�/�+-.- ctn55 G eiC � VALIDAiION
50.FT. h0.OF �O.OF CHEC
�censa Num6er �3�','�3 7 Lic.Clos, C 3g 5�2E .Z STOziES FPM�l�ES � OhE
VAIUATION
Contractor�Of.r Fr�A�jNP,S Dale�— DESCRi7Ti0Y OF WOR[ .//U� hE'`� ❑ S �l .�l O 0
'`, ❑ d 1
�1 am exempt undcr Sec. � �/�/�! �-� ���'� AD� � ,
AL1ER
0.8P.C.(or Ihis rcoson �V ���� �iEpqlR S
Dofe: u5E OF pE11,0. ❑
FxiSTING Ei�C'i
Sign0lura AFPLIf.{1NT iEL. FINAL f
OW�:ER•BUILDER DiCLARATION �P+�•NT� NO. DATE ,��GL
1 hereby alfirm ihat I om nxampt from the Conuoctor's License p�J;-55 FINAL
Law(or tho fellowing reoson(Section 7031.5, 6usiness and � —�
Proiess�ons Code�: ' c 07'
❑ 6UIlDI1.G
I, as owncr of the propo�ly, or my omployees with ADDRE55 �
wa5es os thair solo compensciion,will do the work ond �� C`"�F�
tha structure is not intonded or aifered far sale(Soclion ��'A��T�
7044,Business and Profe55ions Code). MOYING TEL. „� ° • • • �
� I,as owner of Ihe proporly,am oxclusively contracling CONTRaCr02 h0. I • •4�O G
with licensed con�ro:tors to cons7ruct the projec�(Set- qpp;,E55
Iion 7044,Business and Pro(ussions Coda). � � � i �
CONSTRUCTION LENDIhG AGENCY � sEr eAc� YARD Nwv ��TApqO�LiNE wipTH �''"��"
�hereby affirm tha��hero is a construction lending agency for fRONT Q 0,� 9-�Ee
ihe performonco of�he work for which ihis perm��is fssued v i
(Sec.3097,Cir.C.). S+CE
v.i.
lender's Namo
P.C.Fee S Fe.m�t Fee �j O ���`�J`Re�.M
m Lender's Address /1 ,
� I conify fhat I have rcad this oppLcaiion ond stato thai ihe iss���cn r« �V ic;.�a viC�
obove information is correct.I agree io comply wilh oll County In�es��yai�on fea ,` !�
ordinances and S�oto laws roloiing io builJing constr�ciion, io�ai Fea �t�,`/� iD,viq ve„�.x
R and hereby outhorize represeniaiives af this County�o enter
�t upon thu abore•men�ioned pro y 1ar�nspeciion purposes.
�, yj - � •�� SFE REVERSE FOR E1lPlANATORY IANGl1AGC
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