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HomeMy WebLinkAbout1253A 0373A (6) • ` i 1�H�ORKERS'COM7ENSATICN OfCIARATION ' I�tiere6y oif�rm thot I have o cer�if�co�e of�o�,e�,.o,��{ APPLICATION FOR BUILDING PERMIT ' � ir.sure,o�a cert�fico�e of 1V0lAPl3 Compensa�ion Insuranc^, cr a carrified topY ihcreal(Sr,c.??00.Lab.C.� / � � ���I I G �f�A'(C7"NiJD COUNTY OF LOS ANGELES BUILDING AND SAFETY V❑olicy No � �J Company BUIlCi4G Cer'il�ed copy is hereby f�rniihed. FOR APPLICANT TO FILL IN � � PY� Y '+F�' BU'lD'NG � , ADC4_5S ZZ� � � - . L Certified ce s iiled with the counl buildin / IiO�dPPO��mC��. ADD4E5$ 2G��� �. � - Da1e J�('J�'��APPlicanr- / .../ �� CITY 1/� .� �IZIP � LOCAIITV '...\ \ �^ . C `j� CERTIFICAIE OF EXE.M.PTION FROM WORKERS' NO.OF gtDGS. NEA4E5T COMPENSATION INSURAhCE SIZE CF l0T NOW 04 lOT CRCSS ST. (This Srt�io���ed nel br.completed i1 the permi�Is for onn TRACT ��J�� bIOCK �f0( LOT NO. ASSESSCQ hundred dallors�5100)or less.) IJA�BOOK PAGE PARCEL CWf�ER �/ (yC �O 1�F� USE ZCtiE �•'�? I certify Ihat In the performante o(the work for whlch lhis h�� �� permil is issue!d,I shall not employ ony person in ony monner ,� S:ECIAL � so as to become subjnct to rhe Workeri Compensarian Lows. AD7RF55 COhDITIOhS � U Date Applicanl C�Tr Z�P � NOTICE TO APPLICANT: I(, c�ter moking ihis Cerliiico!e of ARCHITECTOR TEI. DiSTRiCT GaCu� ivFE F.rti :'�OCESSED9Y O Exemp��on, you should become subleer 10 1hc Workeri fNGi�FEx NO. F (� CONS�T. ZON: F' Compensaiion p�ovis�ons o1 tha labor Code,you musl for�h- qD��E55 \O `\� v V W wi�h comply w'�h e�ch provis�ons or this permi� sholl be '�� n.� deemed ravokpd. � TE�� STATISiICAL C1A55,FICATION APT. CON'�O. N covTanaoa � S1D Eot .lA1CNo. t� , z IICENSED CONTRAGTORS DECLARATION p� �7 �i�, -7^ CtAS$N0.�OWELL.UNITS I hereby offirm that I am I�censed under provisions of Chopier 9 nDOR[55 ,VO � [i NO.���f'TZ (comme�ting wnh S!!cYon 7000)of D�vision 9 ef ihe Business and � /" ��� Si�SER 1MP Professians Code,ond my license is in full iarce ond ef(r.cl. CITV i� �./ C.tk GLp55 C- 3 �K � VALIDATION /� �� SO.fT.6• / NO.CF NO.CF CHECK License Number 7+7 �� Lic.Glass,� -� SiZE 1Z7 STCR�ES va!r:liES ONE 7 [� O VqIUATION Controc�o�1`.'�-'f1n�-�Doie �. f.•U7 DESCRiPi!040FwCQK h�w : �y "1 2^J� p o��e+�t� � ,� o A�R o � co C� , ;� . . .� t i I am ezempt under Set. � o B.BP.C.Icr th�s rcoeon �d �� s eiL ei2`+'L— pE,�ig � f -� { . •J�G l� USE CF � I Dale: ExiSTivGBIDG.�����- •� C�.�OL � AF�I�ANT !EL. • � •J!`.r U� $ignaturn ' FINAL (PPIM) OWhER-BUItDc2 DECLARqT10N �� ` N`�.7 - � DATE . � �::.�� �3'� I hereby off�rm ihal l am eaemp�from tha Comroc�or's License q�^��SS �,�,/ law Ior�ha iollowing reason�Sec�ion 7071.5,Business and i FINAI ��F�� Prcle•sio^s Ced�)� , .,� ; 6y 'v i� ❑ 9U'lC!NG i � . I,os owner of i!^e prooerfy, or my employres wilh ACpF[$S ' wagns os ihei�sole comp�nsatian,will do ihe wcrk and ' �' C�� �ho s�ruclure i�no��niended cr offe�?d for sata(Sectien lOCntiiv ��.}�� '^ -;/ �=��j']?��� 70aa,Bus�ness and Professions Ccde). M1��OViNG TFI. � Gr7 � 1,as ownr.r of tho propr.r�y,om r.clusively canlracting CONTRACTOQ NO. �,�4U`,i '; • • •7 j wi'h licensed t�n!rec!ors to cons!ruct the projecl(S�t- � � � l lion 704e,Busine�s and Professions Code). A�D4E55 � . a 4 G L II F[(;UI:CD i0iA15�7?A[lr v. [+.i i CONSTRUCTION IENDING AGENCY SE�enCK YARD Mwv �aC�.L�:� w'�fH • . " I hereby allirm thot thcrc is a tons�r�ction lendin�ogency ior �uCv� �������3" tho pe.Iormance af�he work for which this permit is issued a t. �•�,�O_&l 7 (Set.3097,Civ.C.). SiDE P.l. Lender's Aame Q P.0 Fee S , Permi�Fen S7 J�0 �DVA Rnf.N 9 Lender's Address ' � 1 ccrtify Ihal I have read Ihis aFPlitalion and stofe ihat Iho I»uo�ce Fe� GS-..�� IDMA P/C M � above iniormotian is carrect I ag�ee�o comply with all Covnty imesu�o��on fee .t� 8 ord�nonces and Slale laws reloting to buildint�canslru:llon, To�ol Fee • v�+ LDMA Perm.M and hereby aulhorire represen�olivee oi Ihis County Io nmer � opon�he abovx� � / . ..rFTy stx inspecl on purposes, �-'�(��� SFE REVFRSF FOR E%►LANATORY IANGVAGE ��of A�pl�con��� gen - pare ,��� � f--/' ^/', -*"" �\ \ o �� f. � \ \ '�; r� ;, t; _ � \ \ � c.' � : '� •O �` `- - C C \ � ``O ���r (y`( .._ I W _ C, i ` � \ `�� /' .�� _ :� ('I tC� /'"; 'r ' ��f. �C. �` �� \, -✓ �^^\ \ -� i . 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