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�
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