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HomeMy WebLinkAbout1454A (8) . . � 1'l07KER5'CO:'PENSATION DECLARATION 57 1S I hereby affirm tha� 1 hovc a cerlificole of tonsen�to sclf APPLICATION FOR BUILDING PERMIT insure,ar a ccrnf�cc�e cf Workers'Comp=nstlon Insuroncr.,or a cen�fied copy itie�eof�S�c.3800,Leb.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N�. Comp�ny Certified cc is hereb furnishr.d. P.u�LDtvG e�,/ G� H . �'Y Y FOR APPLICANT TO FILL IN nor.vess ..� Y � Cen�fied copy�s filed wi�h th=couniy buildinq inspec- BU'LDinIG Q ticn depnr�men�. nc�FESS �� ✓ ���C� .4 C IOCPtIiY _ ���K� p;11r, �l liconl CIiV / �l �:FAREST q PP /S Q/�:IP C/4 L� CRO55 ST. � 7 r)IC. CERTIFICATE OF EXEh"FTION FRO."d WO4KER5' NO.OF ALDGS. ASSESSC2 �- � CO.'A.PENSATIO'J INSURANCE Si2E OF LOT NC':/CY LOT � h•AP P.00K Pt.GF ppRCfL �This seciion nend net be cemple�ed if Ihc permil is for one 7 U«(UVE rnna . hundred dollors(5100)or less.) iRACi9�l RIOC!( lOT M1O. � �/ Np. a } IF 5�[CInL d �«,iir �ha�i��ha �,•:nrR _C_IY _�y'-J�q- ao.�° �oN��,�o�,5 0 y ����ormance o(Ihe wo�k(o�which this DiS1ItiC1 (;4(;Uv IVYt Fik. FY(XESSE RY V rr.rmit is issued,I sholl ncl em�loy any prrson in any monncr pDDRESS �I � �E/.� �� CCNST. so as�o bemmc subjeci�a ihe Wnrkers'Compensouon taws. . /�(� .,. arr O_!f'�/2 n/G��� C'LZ(p l O J' V � �� G O Dnla Arpli�onl ARCHIiFCT OQ � SIAl15IICAL CLl�S�S}IiICAiION �L / �Pf. CUNW. U NOTICE TO AFPIICANT: If, r.(tcr mo4inq this Cerlificalc of FNG��:EF4 NO CLA55�JO. V_LD'�•�ELL.UNITS� !L E.r.mpuon, you shoul� b^mme subjea to the VJorkers' Compensaiion provieions cf�hr.Lcbo.Codc,you r.�us�fcnh• ,•,�ceess � Sil':k�!�!AP wilh comply wiih such �rovisians or �his p�rmi� sholl bo E` — dr.emed rrvoked. C04TR4RCR ��� �;� ��(pQ ne.(� Mi�� VAIIDATION LICENSED CONTR�CTORS DECLARATION I hrrr.by offrm thct I am Ircr.nsed undnr provisions of Chop�cr 9 ACDCE55 lK. �"n� � VALUATION (tommencing w�•h Senie�7000)eF Division 3 of ih�Business r.nd ��` Profess�ons Ced=,and my licr.nsr.is in full for���nd ef(ett. LITY C1n55 S d U� � S(1.FT NO.CF Ivp.CF C�+ECK Licensr Numbcr Lic.Closs SiZE STpR:ES � FA!A�lIFS � O�E CESCRIPiICN OF WC7K h=tiy �1 S Cenlrepor Dafs I n ^rD lEL ; / � I om exempf from Ihe licens�ng requirCmenls as I cm o — � (,tL L� lice.nsed archii=u er a registered prefess�o�al angine�r nt7ER � FINAL �� (1�(1�'� I octing in my prafcssional ccpot�ly (Secticn 7051, R�YA,R ❑ DATE Busfness and Prolessicns Cede). USE C' FINAL �� � � �2 3 I F%ISiiNG 9LDG. CEh'CL ❑ Lic.or Reg.No. Da�e Acp�ICA'nT Tei. BY I •8 b$8 0 O:'.'�ER�9U�lCER CECtnRATICN i`4�tiT� '�'��. I herr.by effirm thct I am e�amptlrcm itia Ccnrra�ror's I�CF�SP • •�j(j 8,8� u law{or i!:e fcllowing reoicn(Seclion 7071.5, business ond xC�J:F55 Prcfcssicns Codej: ' ��:.:�; O 2 G�!"$z ❑ � BUi�D'NG ' I, as owner of ihe proFr.rty, or my employr.es w�ih qC�;;cS E�P� e�p wages as the�r sole tempenso�fon,will do�hn wo�k ond �x �he structure is net in!ended or c(lered for soie(Se:ticn ���A��Tr �� � 7044,B�siness and Pro(essions Code). r.�pvvG IEL. i � I,os owner o!ihe preper!y,ori r.rcl�sive.ly tcntra:iing cCnliaaCiCe h'o. a " wi�h licensed mnlrncb�s to Ce�s��oU rhp pro�ecl(Sec- „�CF'S5 non 704a.Business and Prciess�ons Cod�J. RFOU'REp Tpi�L 5F19A�Y FRU'•� F%ISf. COYSTRUCTION tENDING AGENCY SEI gnCC ���� H"�� P�O� li!.E \'I!DIH I herrby nf(irm th�t them is m m�struction Ir.ndinq agenty for p;;�y� � �he�rrformonce ol rf+e work for which Ihis�?rmit is issued o� � (Sec.3097.Civ.C.I. s'oF P L. Lendcr's Narnc / '� lr.ndcr's Add�ess P.G�ce 5 (Q�O Pprmn Frn W I cenify th��I hov.P rcad this cpplication cnd sloie iho�ihe kwonrn Fee abovc infonna�ion is corrvct.I n��nc�o cemply with nll County a Im�s��r,o��en Fee ord�nonces ond S�ore laws rela��n��a build�ng construciion, � nnd he�eby ao�hc��ze represeniaives af ihis Caunty io enicr TObI FCP a �pon ihe obo�.e�meni�oned p�eperiy fc.insocclion purposr.s. o SEE RFVERSE FOR E7(PLANATORY LANGUAGE � Siqna�re ef PFpl�can�c.l,;en� Do�c ' y s :� ' � o •• �' � � T S i: � � � e � `.' cP p` ii O' O O n ,i 4 a � C�� � o o � o " =' ` 'c .o �c o o ��. T� " 1 0 C '� �' �, ^ � . n � � � A �� o n c, � n � .c =' � i� �, � � -.� N r � :� ' 7� -�,��, c t � �. � , '" Tr T N O O O 1 �� 4.Gj L:'•) <: P � • . N m V � �O ti . 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