HomeMy WebLinkAbout1079A 'pRKCR$'CO^F.`NSAiICN DECLARATION �
`��,���,.eo}Vlokr.n''Compnnsa�o���surancef APPLICATION FOR BUILDING PERMIT
l�pY iherec((Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
fP� ,n.. / Compony 9U'LDiNG �rf�,, � n
� Ce�,�f�ed ccoy�s he�e6y fum�shed. FOR APPLICANT TO FILL IN qD�RFSS Z___�M1�"�"��"e
� � Certifie.d copy is tilyd wlrh rhe couniy 6uild�ng inspec• pCDRE55 ��J-t oZ. 5���'l+L�e���SC 7-N•
, 'tion deponmem. ( r1
n "�1 ' cti7�s
Da�c APPIicoM Cliv `JI•-II�Z.CII'Q TJ�� �. Z�v IOCAt�7Y � <<^-�'i.�-0��" � W�
CERTIFICATE OF E%EMPTION FRO!.1 WORKERS' y NO.O'e�oGS. �( '.:aeESi
COAIPENSATION INSURANCE 5�2E OF LOT 1�0.SS rIOW CN LOT � :4055 ST.
(This seciion nr,ed noi 6e tomple�ed if�he permi�is for one c7 e�55ESSO4
hundred da�lars(5100)or less.) • TaaCT d� O 9LOCK� LOT NO. Q NA7 BOOK PAGE PA7CEL
OWNF4 �C-� S. 4�fU�S NO.J I'��� USEZOti'� MA7
�ceri�Fy thol in ihe performance at�he work(ar which ihis �" � C�` '
permii ie Iuued,�sho�l nol employ ony penOn in y manner S�cntr-�ulxs� L+�• 2~ SPECIAI p�
so as ro be ome ubjetl lo��e Workers'Com .sa!i ows. AD�qESS .�S � .ZO CONDIT1045 �
p ,� ` r 7G s �
' GTY �n�b n0 Ar Z�P
Dole 'L� o AFPlito^I ARCHITfCTC4 �E�� � (� D'SiRKI GROUP ttPE FiRE �30Ct55i�91' O
NOTICE O A PLICANT� If, o(�er making�h Certi(ica�e of ENG�ti'EER �415 NO.S�/'G 1S CON555yyy��� ZO'.'E F-
EKemprion, yov should beceme subjecl fo ihe VJorkers' // � � 0�� �U
Compensalian provisions cf ihe Labor Code,you mus�forth- A07RE55 S C �� «'
iih tomply wilh svch prorieions or this permit shall be TEL. StA7i5iiCFl CLA5SiFICAnON PFT. COWDO. N
deemed revokcd. �CNTRACTOR Iv �i NO. �1 1 Z
UCENSED CDNTRACTORS DECIARATION ��M� No ttA55 NO.�1—D'h�ELL.UMTS
1 hcreby aff�rm ihot I am licensed under prov�s�ons oi Chapier 9 nD0=E55 �`•hq�rAP
(commencinq w�'h Snclion 7000)c�Division 7 of�he 6usiness ond UC.
Prn!essions Code,and my licensP is in full force nnd elir.ct. CiTV CLA55 BK � VALIDATION
SQ.fT. NO.CF NO.p� CNCCK
liCCnSC Numbcr lic,CIo55 SIZE STOR!ES FAM.IL!ES ONF
I VAIUATION
DESCRI7fION OF WORK �O U I�nEs tiEW � S� �O/\ d�-
ControUor Datv c n nr ADD � �� , .:� (j f.4 F�
�I em etempl undr.r Sec. ;�OO�f�."M"�,.�-� r � ��,v�L ALiER ' ' • • . .
6.8P.C.for Ihis renson �� W�r��� T1 L'� £F9As2 � S � • 1
Da!e' USE O� CEVOL ❑ � • �i;Q�.ri
ExISTING BIDG.
S19nOlU�'` AP�LI�P.NT � TE . FINAL ` � f � a��'.''�•l J�
OVJhER�pU�IDER DECIARATION �PR''�t C��� �� N� ` DAiE �'��•�I, /
I hereby cffirm thnl I am erompt from 1he Contrncrar's Licensn pDCor55 �` S�e�' ��%�' 1��2� h FINAL 1� il�(�—f;7
law for tie followine�reason(Section 7031.5,B�sine.ss and n ��j�
Prof �ons Codc�: ruL(�� y +� �
o��ip�N�, �
1, os owner o1 tha prcperty, or my nmployees w�lh ApC�E55
ages as iheir sole compensa�ion,will do�he work ond '
the s��ucture is not intended or oHcred for sale�Settion IOCAIiiv
70�d,BuS�ness ond Professione Codr.). ti'�OV�NC+ 1E�'
� I,as awner ef ihe properfy,om e.tlusively con�rocfing COviaRCiCR �'��
wilh licensed mntraclon lo constr�c�tho projecf(Seo q094ES5
tion 70:4,Bus�ness and Crofrssioni Codn).
CONSTRUCTIC`J LENDING AGENCY SET gp�K VAstD HWY IOTAF�EOTP`nE �� w��iN
1 here6y ailirm Ihollhpre is a tons�ruclion lending agency(Or faONf
Ihe performonca ot tha work for which this permit it ise�ed V l
(Sec.3097,Civ,C.�. SicF
v.�.
lende�s Nome lD!lA Re},M
� Lender's Address v.C.fae S ve.mit Fee � � U—"C� ,
� I ter�i(y�ha�I hava road�his applim�ioe and ita�e that the �ssvo�ce Fee l� IDMA P/C N �
above informa�ion is correct.I ogree lo�omply with all Counly Inves��gonon Fee
$ c�dinante�and Staie laws relo�infl�o building tons�ruction, To�el Fse (���0 lp!M p•.m.N
ond ha�eby auihorixe repreeenioiives of ihis Co�niy�o enter
� upo �hn abov - en�io e ap=r�y for Inspec�ion purposes.
A � ,y p,�, � j SEE REYEKE FOR FX�LANATORY LANGUAGE .
S�gra�ore ol nppbcom o�A9ent
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