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 _ - - I _� ; `� � �,,;_- — ------; —.-�—_ -�—��;—, ---�-_— -- ; --�: �---- ---I_I ,�Z � :, I ��� o �� � I r � 1 � : � 1 r• 1. -� I� : rt �' � ' • . �� � l': � _' 1 .",�. I �: 1 . �i — -I F - Y = � �, � ! � r ; � ri° � i; _ I �I D I. , _ -' c � ci � o c'�i � o p � :� + "� I; a li . ' ' n _ - - i� i .. - �• ; e C I , I� ` 7 I I ^ II r � � T— I ii _ I I .� i I� � ° '� i I �° _ � � _ 'I ; I � i a -- -- — -- — -- -- -- - — — — � � � � � i �� i � . 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