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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 S�qn wre ol Appl�canl or Ageni Doie s �� �r�a.' . U' . _ a c' � : J: „^� � - � .j , z' ' _ ' - � ? t c...". _ � i. . ' . � � / � �. •i �� C G. T c ' i. � .i C . � . � ' — ` � _ ` CCv J'r i �y . 'I _ 4�'� z ,G _•. � ^� �,~ �'�•F i. ' • � :•`� .."3 v^�� K. `3r:i . � . ,:C � ` . =_. =� � •t: � � 'G`�- =,�1,�, . f� :�,- '^ � Q `�� � S � � : ,), v 4 � � .� 4 h r . y~ :� ��. i v .� � r � (�� C � � {"'� � S ` � , ��� � C� J L' _ ^ .,, "G `` - y. � i. 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