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HomeMy WebLinkAbout1460A VlORKER$'CO:'.PENSATIO!J CECIAftATION � insurebor�arce.nf�a'•cofWorkrrs''Com'pensa;o���;�:a��" APPLICATION FOR BUILDING PERMIT o�o ceni�jd cepY�hereol(Sec.3900,Lob,C.) � �OUNTY OF LOS ANGELES BUILDING AND SAFETY P31ityNo. �O 7.A''�omPany �ff��i�l4F � Certif�ed ccpy is hereby iurn�shed. FOR APPLICANT TO FILL IN AD^D^.ISS u�-a�L ;z2 � - /� � C� �Ce�riNed ccpy is��led w�lh Ihe counly building Inspec- gURDiNG �f / iicn deponmen/� ACDR'.SS / �1� �7F�.i�(o F f?$t` Da�c �n/�l�pplicanf—� .-/.� CITY r�i� � Ziv lpGIITY �. i._'U� ��r CERTI�CATE OF EXEMPTICI+I'kR0.41 WO4KER5' NO.OF eLDGS. hEAREST CO!��PfNSA710N INSURANCE SIZE OF LOT NOW 04 LOi �RO55 ST. (This sec�ion need no�be tompl.ted if 1he permil is for ane � �7 a55E55CR hund�ed dollars(E100�oi tess.) TRACT � P.LOCK LOT NO. � / MAP BOOK PAGE 7ARCEL IEL. USE ZOS: MAP O�ti'NE4 � � � NO. I cert�Iy�het in ihe performonce of the work(o�which this �^ �� �� �O � 3� permif is issue.d,I sholl nol employ any person in ony monner ADD4F55 7� � 7 -f'�[c � S::CiAI �y so os�a b�come subject lo Ihe VJerkeri Compeneat�on lows. �'��'� CRJ U COn�DiTiCvS p � �, U Dare Applitont CITY ,n- ZI? � ARCNITECT OR TFL. NOT�CE TO AP?LICANT: If, o}ler moking lhis Certificofe of DIS�RICT G40Ua TYPE fIRE FZOCESSED BV O E.emprion, yo� should become svbject to �tie Wo�keri FhGihFER NO. CONST,. ZONE U Compensaiion provisions of�ha Labor Coda,you must lorth- aoDaE55 t� ►L� -tJ ��-� � wilh comply with such provisions or Ihis permit shall he n. TCL / STATISTICAL ClHSSiFI�qT!O A:i. CON70. fn deemed revoked. CONTRAC70R cnSl /J I G�/C NO.( x� '� z LICENSED CONTRACTORS CEQARATION /J ���, QASS NO._J�D:4FLL.UNiTS ' I hereLy e!firm rhor 1 eri Gc�nsr.d onder provisions of Chap�er 9 ADBpE55 � l%�e t, NO. 2�l� �>� (commencing wl!h Sec��o�7000)01 D���s�on 3 0(rha Business and ��� SEY.'�R MAP ProfPssions Codr.,and my license7is in full force ond e(fect. LiTY ttA55 �) C-��� eK � VALIDATION Z l-7`f S L� '� 50.FT.7 `� NO.OF NO.OF ' CH'CK Licensa Number G Lic.ClalS �� ���� SiZE .J�V� STC4iF5 FA.VILIES O�E / A VALUATION ��"� ���n COnlroctor r�>�/���po�r. � ���� DESCP�PTICNOF WCRK h� � s � [� ;i • • • • • � X L ADD � �I am e�empl undCr Set. ' (� 9.8P.C.far this reoson // �I� `�7/�� `�'?rn R�PARR Q s I ' •[1 3.'`n�. O Da!e: U:E CF ��^a � • :.A ll�i J EXISTItiG BIDG, ❑ Si �clure AFR�CANT ` {� � TEL. Q 4,� �`�7 � OtYNER-BUILDER CECIARATION �R�NT ^✓JA �i,lr.'f-'P?/ NO. �Z'17�5^� DATE�S IC/D 1 hereby affirm ihai I am azampt from the Contractor's Licenso n �/ /� � low for the follawing reason(Section 7031.5, Business and AC�QESS t'�'.S'r Y.. ���5��='� Pe�2en�• !,/q� FINAL ��L� Profeseiors CcdeJ: __n� 6y � ❑ BU'I�IVG � I, a�owner of nc�properly, er ny employees wiih aoD�!55 wages os Iheir sole compensation,wili do iho work ond � i�e s!ructure is r.c�in!erdrd or efiered for eale(Sec�ion «CA��T� 70dE�BUS�IIP.3]OIf(I PfO�P.SSiDIIS CO(�9�. �•.OVING TEL. � I,os owner oi Ihe preperly,om e�clusively conlracling CONTRACTCR NO. wi!h licers^d cemracrars to cor.s!rvcr!tie project(Sec- qDCaESS ��on 70ae,Bus�ness and Pro�ess�ons Code). CONSTRUCTION lEfvDING/1GENCY ��Ou:R`'J yqRD H�W �OIAI 5'_I:3ACR d SE7 6ACK 7�7CD,lihE Yr:�TH I hereby olfirm ihai there is a cons�ruc��on lend�ng agency for lNCNi thr.performonce ef ihe work for which�his permit is issued p L (Sec.3097.Civ.C.). 5�^E P.l. lendei s Name z., v ioM�a�f.a Lender's Address P.C.fee E cerm�r Fee ' - I tertily that I hava rr.ed this opplica��on ond s�ote tha�ihe i�suo�ce Few (O • ID.MP.P�C M _ obpvq iniormation is torrr.ct.I ogree to tomply with oll Counly Inves��qar�on fee nrdinonces ond Slate laws relating to 6uilding conslruclion, To�al Fee . �� lD!AA Prrm.N and hereby auihorizr.reprrsr.nta�ives of Ihis County fo r.nter opon 1Fe abp menGoned prp p��y Ior inspecKon purpoees. A `\'-/ ��jt/L,C�GC'" ` � �D/�'� SEE NEVEIISE FOR F%PUNATORY IANGUAGE `� Signelur`�Appl�cam or Agenl por� �._-� .. ..` - T�- - -- J- -:- i,:.�; -•-� - , ;,- .��,. „^� � c =' � ' _ ;. - �) � `:I� '_' :, . � � � _ �\ `�^—TJ �'' � � f�, 2' 1:: r -� r � � v ' ` I —3� T� � ^ 7 ?� � t : ,�' _ _'C: �1 1:J n• n � ` I � 'n= � , $ �� � j � o ii�; n c � _ - I � I ', '- �� - - 'o �o J - w �i` .� f, � = _ i C �C . I_ '— C V� � i w i 17 I I I I � I' o ` _ I _�_ i� z � I c I I ;I° O � _1_ _ _ � � ��� � __ __ __. I � I I�.n C ' �. t � A c I I � I , C� � � I� I -� ° � ; � � � - ' !o` � � � . �i n a y I i � — — — — ----- � � I I I la . , � o � . li " . i = � I I. N I D G II �c 9 � I � v o D I � � o' m li v c � � �O I� < I I I ; ' � �I G —- —�—� —•— -- L — i . , . � . Z � � . , m I : n . � O A fA 0 N T , N I I C: ` _ !1�J T� ! � ,- ` �-= ^� `= ^=1 } - Y ': �``,' �`_ i _ _ - ^'i.L � c. , � t � � L -G p ', �� �' � = ^. 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