No preview available
HomeMy WebLinkAbout0841A 2795A 2797 IVlORKERS'CO.�"•^ENSATION DECLARATION ' � insurebor�afce!ri�fta1�r,of\Vorkesr�Com�pensa�on��;��P��" APPLICATION FOR BUILDING PERMIT � or a certi/ied coay�hereof(Set.3?00.Lab.�) � � a COUNTY OF LOS ANGELES BUILpING AND SAPETY P❑olicyNo. ��3 Company ��'w'�`T""� 6UilCI4G 1' Cer:�4�ed cepy is hr.reby fum�ificd. FOR APPUCANT TO FILL IN ACCP:$5 ��`� �Q � _ � Cerufied copy ie filed wi�h the coon�y building inspeo ACCQ'.SS 7-+7 S�� GNaS� L��� ticn depertmeM. �Da�e d' � Applimnl �i.� "'_ .�� CISY ���M�Nf� . !"+ Z�7 IOUIITY . CERTIFICATE F EXEh1PTION FROM W ERS' SRE OF LOT 263� 5 p, NO.OF elDGS r NEF+4EST COMPENSATION INSURANGE NOW CN LOT 1 CRC55 ST. � (Th�s eeclion need nol be cample�ed if tho permil is for one 2 -7 ASSESSOR ��, hondred dallars(SI00�Or�eSS.� TRACT 7O /S 9!OCK S 10iN0%F I MAP EpOK GAGE OpRCEI OWAER 7FfoMRS l��u NOv -¢ USELONE MA7 'Q "�-�;1 � I tertily�hae in�he perfermance of ihe werk fcr which this '/,' � .��I �,� N�' `��� � permit is iSs�ed,1 shall nol�mploy any pe�sen in any monner pDDpE55 2.�r� Sr�� 1-L C SZ '�-r'+iY� ��FGa� � so as to betome subject to thr.Vlorkers'Compeneo�ion Laws. A ri� CCN�ITIONS p urr �►AMo�/A 6 P z�r v Da�e Applicnnl qRCHrtECT CR T«�C8[fI�_ I D4iRiCi G40UP ttFE fiRE �'�CESSED BY O NOTICE TO APPLIGANT; tf, ofler mo4ing thi�Certifimte o4 ENGiNfER S��N� C N0.1 �0.' ZOn' F-� Ezemption, you should become eublctt to ihe Workers' � �' U Companso��on p�avisions of fha lobo�Ccde,you mosl lorlh- ADDQtSS �s.���. H���n7 5 i- �(UfAMafrq l� �- � W lih com I wi�h such rovislons or ihif rrmi� shall 6e �' p y P P� � TE' f� SiAT:S:'iUl ClAS$'FiCATION A�1. COY7J. fn dcenad rovoked. Ccr+rxnCrcQ — ��� g> >>^�3? �1 { Z LICENSED CONTRACTOR$DECLARATION i��.� RASS NO.�OwE0..UviTS I hereby al(irm�ha�I am licertsed ander provisiona af Chop�er 9 ADORES U� "�>0�f� NO. 'r� �� �p,�R IJJ�.P (cemmenting wiih Seclion 7000�o�Division 3 of ths 6usiness and liC. Prci!ssio�s Code,ond my licr.nsr.is�n full Iorce ond e��eU. C�Tv �rK O nn55 � BK � VALIDATION p /--/ (� $Q.FT. NO.CF NO.CF CNECK License Num6er �/d �'1 C lic.Clns� r SIZE � � STC4iE5 FAM�liFS ' CNE YAWATION � �� � � new ConvacmrS�l�._LL�u� Dare �o"�-�J CEKR!PP.eveFwceK DDf /DA! f��� !'iSTt F)1� ' � FULL�I11 ADO � �I am exer�C1 under Set. ALTER � :%Q U 4.I fl 8.8P.C.for ihi3 reoson �°pq�R s . , UcEOF ❑ .Z� DO[7 : . .ZJ �a": exisnv.e:oc. S I N�C� PHM�L °`•"OL ❑ Si9nOtUIR AP�fCRlY7) . TEI. -! FINAL n I • � G�J Q` OWNLR-BUIlCE2CEClARATION � ����� ��� NO. 2' r�f'�7 DATE G�� �� � •• r I he�eby offrm ihm 1 am e.emp�1rom tha Comroc�oi s License 2,,f'�a /,tJ, /L'//{� Sr: r4�-N• �F}7/FC� � ° i '�-�.�'.1� low 1cr the foltawing raasan(Sr.nian 7031.5,Businefs ond pDD:F55 FINAL ,� ProFessions Code): F2:,: BY �, � 7�� � aP.U�LD!N3 1, p7 owner of ihc properly,cr my emp�oyees wlth aCD�E55 l/� wagr.s os their sole comFensat�on,will do the work ond ��' I"" ��� 1he slruaurn ie not in�r.�ded or affe�ed fe�sole{5?c�ion �«AUTY � ���n`- 7044,BuSinCSS Ond PfOfCSSlons COdCJ. h•OV:NG TE�• /'P � I,as ow�e�ol�hr.prcpe.ty,am ezclusively can�racting CONTRACIOR N�� z3 ��,��J� wi�h licensed con!�oc!ors lo construc�Ihe preiect(Sec- r r�on 704a,Bu�iness ond Prcfessions Code). %+��RE55 Q . CONSTRUCTION LENDING AGEf�CY Sfl 9ACK YARD HWY iVTA�RC�„LLtiE� 'I W DfH S Z•� 3 i: • • � � � I hereby of(irm rFat ihere is n conshuU�on lendin�agency for ru0'v� �U- 2.0��� � • I �5 Q J� �he peiformvnce oF Ihr.work ior which�his pc�mil ie iesucd � P.�. (Sec.3097.Uv.C.). 5'=E � � a � ;(1���u P.L. lender's Nome 1, lC!:A Ret.N � ��,L�'"8% P.0 Fee S ���'Y � � Pe�mii Fre O� � lender's Address �f ��'7' ,, . !' � � I cer�ify thm I have�eod th�s opplicmion and smte thm ifie �Z• /3 hsun�<e iee t 0� v - i0!1J.P/C M (.�e-�[� �� obove inlorma!ion i�correct.1 agree lo comply wiih all Counly i��rs„g�i,on Fee �n{ 7� I $ ordinantes and SIa1c laws relafing lo building tom�roctian. To�ol Fee /v O��u t�MA Perm.M � �'�� and hereby ou�harize represemativcs of this Counly io en�er / I� 1 opon�he ahove•ment�oned o�sar.ction purpases. ��Q� S'L� ' 7 � l U—�^� SEE REVERfE FOR fXPIANATORY LANGIIAGE ��,� � S�r,no�u�e cl ApD ani or Agem Do�e Jo'�—&7 � - .�-- � r. _ �L 1�. .• S;� O �— G r'� �t' G' �:? I1 -i.. . -' � � `. � � �: r � � fl .�� ",�, t �� . � _.; ' �' �, - r �I;r �- _r :, ' - �i: _. � �; ' � o b s r: 1 _ c - c „ - �� q " = ' _ � i r � ii I M `'' . . � ,I r �C ~- • ''? r� ,I O ,.'<'- . (!: � ' r I . `I' ' •• ✓ -C � 1 t 1 l . .. . _ 17.' r�� "� L ` I N ,'I ~ ' �' r 1 '�-�1�r4:z � . �' ,-, _ � - {y �� r `� �.�""`I �� I `—I � '7 .'' � ' � A ' ' t