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HomeMy WebLinkAbout1644A 2187A (9) � WORKERS'C0.4".�ENSATION CECLARATION I' /� � I he.eby af�;,m ,�a,� �a��a certiFica�r.o<<o�,��,�o,P�� APPLICATION FOR BUILDING PERMIT � � ineurr.,or a ter��(ico!r.oi Workers'Compertsai�on Insurance, L� c�o tert�i�C'�COpy ItiC�POF�SI!C.�QOO,�Ob.C.� �gir1C��J�Pt (�IlYT�O�IAL AMEQi� COUNTY OF LOS ANGELES BUILDING AND SAFETY o��cyNo. omPony � Cc�tif�ed copy�s hcrr.6y furnished. FOR APPLICANT TO FIIL IN eunotn;G nooR:ss L4�-{�CO E. STA2.. �.-r-• Ccrrlf�ed cepy is filed w�!h�he eounry b�ilding inspeC- BUIID:NG �Y e �` IiOn dC��rimenl. (� ADGR[SS aJ�� l��• oo�e q � �n�Pi��a�� CA-riO �ihC� aTr�! �AM R_ z�v �l"7 '� iocaurr �iArYl �AR CERTIFICATE OF E%E�1.PTION FROM WORKERS' n+0.Oc BLOGS. NEn4EST ' CO=M.pENSATION INSURANCE SRE OF LOT NOW ON lOT � CROSS ST. (This settion need not be compleied if Ihe permit is for onc $� o�aK lOT NO. ASSESSOR h�ndred dollors(SI00)or lefs.) TRACT MAP P.00K PAGE PARCFL ON":ER��4l��D l-ASS� NO.,� U ZOhE /�P ��Q I cenify ihat in�he performonce o�tha work for which ihis � h�. permif is Issued,�shall ncf employ any person in ony manner ADDRE55 � C. S"�11 Q. 1 5����A� n- so es to he:eme su6ject to the Wcrkers'Comper.ecticn Laws. • C CONDiiiC':5 0 atr��Atr1pt10 Q ziv 9 l'� � v Do�e AFpliconf ARCHiTECiOR TFI. � NOTICE TO APPIICANT� li, oiler ma4ing 1hi!Certificala of �ISTRICT GROua TYPE F;RE P40CESSEO Bv O E.emp�ion, you should becoma su6jetl to ihn Wcrkers' FNG!NEER NO. ^v CC'��;1 ' - �pwt� 1- Compensation provisions of fhe Lobor Code,you mus�forih• q07aE55 �� \\ v�— �V � lUil with comply with such provlsions or lhis permit sholl bc TEL. 1 STATiS'iCal ClAS,'S��'.C!�iON A?T. CCn��O. u) delmed revo4ed. CONTRACTCR �� Np. t `']�t�-� �\ IICENSED CONTRACTORS D'.CLARAiION p ���. �1n CLA55 N0._LD'h?lL.UNITS Z I Feroby oFiirm ihot I am I�censed unde�p•ovisions oi Chapter 9 ADC:E55 '1C,��Aid�ty � NO. 41 1 b� (commancing w��h Sec�i�n 7000)cf Division 7 cf ihe Busiress and '.` ��� SEWER MAP Professiors Code,and my licensr.is in full force and effen. �iTY �J�LIJIY� CLA55 C� �� VALIOATION r_L(. (� SO.FT. I� NO.C' NO.Of CHECK BK' �'' Lieer.se Number����`�' ` lic.Clase -`�� SiZE �T STOQiES FAMI�!�5 � OhE P��O�� p (y�[�� VALUATION Co���ac�o� �n� Do�e a 3� `' • ��KR!�TICN OF WC4K $� T -J6�S ^� ❑ f � �j S� ADD ❑I am c*emp�undcr Scc. Q-� LATT1 -Qr AITFR � ='1 6 i;,4 r'{ � 8.8P.C.for ihis reoson REPA!R ❑ s ". • • .�J F Do!e: USE CF ` ^� C�:�_a E%I571\G BIDG. - 1�nt� ❑ Signa+ure ACPLICANT TEI. FINAI J • •J 7�.J� OWnER-BUILDER DECLARATION ��x:4T� � ( A'NNO. 'T]r{- � DATE + � ;�.;(j�; I hereby affirm ihal I am oxempt from�he Contractor's licenee e� �IAI,LGY-�'H-V�I4�.*1 UT Law for ihe iollowing reoson(Seuion 7031.5,�usiness and ACCaE55 FlNAL G 9.1 9-��E Profeestons Ccde): 2 ti By � eu•�o�N^ I, os owner af Ihe preperly, or my employees wi!h AC�RESS wagr.s as Iheir sole compensa�ion,will do Ihe work and ��a��Tv � ihe struc!ure is net in!ended or cffered for sale(Seclion 70<4,Businr.ss and Proirtssions Cade). h�Ov�vG TEt. � � I,ns owner of the preperly,am e.clusively conlracfing CCNTaaCtOR NO. w��h I�censed tonn�c�on to co�s�roct ihe p.ojrtcl(Sec. qDD".FSS i�on 7D44,Business and Profess�ons Cedn�. CONSTRUCTIO.J LENDING AGENCY SEi EACK �ARD HWV �V�AFRpP.��ti��V,� WID�Fi ' � 2, � r 1 I hereby affirm Ihot ihere is a[ons�ruction lendinc�agenty ior {kL,y� r• • • . • � thr.pe��ormance eF the work ior which this prrmit i�issued P�, (Scc.3077,Civ.C.). SipE � . .�C J U P.L. londer's Name � r !'''� lC'.�A Ref.N � •�`O ��% � lender's Address P G Fee S S PP�TiI FPH I Q �d IG.GS-&3 a I cerlify that�have read this applicalion and stale that the Issuonre Fen �Q ID.'�1�P/C M obove informolion is correct.I og�ee fo comply wi�h oll Counfy Invesiigoi�on Fee ord�nontes ond Storn lows relo��ng to building consnuciion, iorol Fea � IDMA P�rm,M and reby auihorize representailves of this Co�n�y�o enter _ up hn ob�nyr.- iianr,d prope�iy for inspec�ian purposns. 1.•. A1, qqqrrr��� 'L p�ct ` (Jg�� �T 1.� SEE REVERSE FOR E%PLANATORV LANGUAGE a_� S�gna�ure ol Appi�cen or Agem pe e ' ^ii ` � a r ° -� � ' �i`�^ .�' 1 C� '� _ _ i I !;c` o c = � „ ` `'�Ii r C�, � ;: , c, f � - =I, �' -- c7 - . - _� �1: � � - � � . ,�� � :� _ �' I - - , ; �; ?'�'' � a F a�� I � %-' �`�� '� '' y � ��- c N � { ! o "c = ` I,. . _ _ �� v • � u -- I `" �-� I < �� _ ,� I� ° ,.i �:� I � � � � i • I � � r�` � I' � ] ' - . -- • I I N __.___� �,.. 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