HomeMy WebLinkAbout1079A (5) '��KCR$'CO":F.`NSAIICN DECLARnT�ON �
����,����.eo}Vlokr.s''Com�pnnsa�o���surancef APPLICATION FOR BUILDING PERMIT
lSpY�he�r.c((Sec.3800,lob.C.) COUNTY OF LOS ANGElES BUILDING AND SAFETY
fP� ,n.. / Company 9U'LDikG �rf�,, � n
� Ce�,�f�ed ceoy�i he�e6y furn�shed. FOR FIPPLICANT TO FILL IN qDCRF55 Z___�M1�"�"��"e
� � Certifie.d copy is tiled wirh rhe county 6uild�ng inspec• pCDqE'.5 ��J-t oZ. ST��'1'L�e���SC 7-N•
, 'tion deponmem.
' cti7�s
o�,� Ap��,�o�, ��,� D�Ani�rr0 b�l � ZID �«<��TY � ��..�.,._-o...- r� w�-
CERTIFICATE OF E%EMPTION FRO!.1 WORKERS' y NO.O'e�oGS. �� '�eaeESi
COAlPENSATION INSURANCE 5�2E OF LOT 1�0.SS nIOW CN LOT :4055 ST.
(This seUion nr.ed no�6e comple�ed if�he permi�is for one c7 e�55ESSO4
hundred da�lars(5100)or less.) • TaaCT d� O 9LOCK� LOT NO. Q NA7 BOOK PAGE PA7CEL
OWNF4 �C-� S. 1�fU�S NO.J I'��� USEZOti'� MA7
�cerilFy thol in ihe performance at�he work(ar which ihis �" � C�` '
permit is iuued,�sho�l nol employ ony penOn in y manner S�cntr-�ulxs� L+�• 2+ SPECIAI �
so m ro be ome ubjetl lo��e Workers'Com .sa!i ows. ADDqESS .�S �. .ZO CONDITIONS �
p ,�� � I�G J �
' GTY �n�b n'D Ar z�P
Dole 'L� o AFPlito^I ARCHITfCtC4 �E�� � (� D'SiRICI GROUP ttPE FiRE �YOCt55i�91' O
NOTICE O A PLICANT� If, o(�er making�h Certi(ica�e of ENG�ti'EE2 �JIS NO.S�)'Q 1.S CON555yyy��� ZO'.'E F-
EKemprion, yov should beceme subjecl fo ihe VJorkers' // � ,�- 0�� �U
Compensalian provisions cf ihe Labor Code,you mus�forth- ADORE55 S C �� «'
iih tomply wilh svch prorieions or this permit :hall be TEL. StA7i5iiCFl CIA�SiFICAnON PFT. COWDO. N
deemed revokcd. CCNTRACTOR Iv �i NO. �i 1 Z
LiCENSED CDNTRACTORS DECIARATION ��M� No ttA55 NO._l—DY��ELL.U^:ITS
1 hcreby affirm Ihat I am licensed und?r provis�ons o�Chap�er 9 nD0=E55 �`,hq jrAP
(commencinq wi'h$nction 7IX70)c�Division 7 of�he 6usiness ond UC.
Prn!Pssions Codr„and my licensP is in full force nnd elir.ct. CiTv CLA55 BK � VALIDATION
S�.fT. NO.CF NO.p� CNfCK
liCCnSC Numbcr lic,CIo55 SIZE STOR!ES FAM.IL!ES pNc
I VAIUATION
DESCRI7fION OF WORK �O U I�nEs tiEW � S� �O/� d�-
Controuor Datv u
i(c00 R�-R F � �F!(�NGL= ADD p :°1 G 7.4�l
�I Cm etempl un�IPr$e[. �f�.M,.� q�1ER ' ' • � � �
6.8P.C.for Ihis rrason �� W�r��� T�L'� £F9A=2 � S � • 1
Da!e' USE O� CEVOL ❑ � • �i;Q�.ri
ExISTING BIDG.
S19nOlU�'` AP7LI�P.NT /' � TE . FINAL ` � f � a��'.''�J�'�
OVJNER�pU�IDER DECIARATION �PR'Nt r 1�M� ry� N� � DAiE �'��•�I, /
I hereby cffirm thnl I am erompt from 1he Contrncrar's Licensn pDCor55 �` S�e�' ��%�' 1��2� �'7 FINAL 1� 0:�G—F;7
law for tie following reason(Section 7031.5,B�sine.ss and d ��j�
Prc1 �ons Codc�: ruL(�� y +� �
°U':7!NG �
1, os owner o1 tha prcperty, or my nmploye!S w�lh ApC�E55
oges as iheir sole tompensa�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.). M.OV�NC+ 1E�'
� I,as awner ef ihe properfy,om e.dusively con�rocfing COviaRCiCR �'��
wi�h licensed mntraUon�o cons!r�c�iho project(Seo n09aES5
tion 70:4,Bus�ness and Crofrssioni Codn).
CONSTRUCTIC`J LENDING AGENCY SET gp�K VAstD HWY IOTAF�EOTP`nE �� w��iH
1 here6y ailirm Ihollhpre is a tons�ruclion lending agency�Or faONf
Ihe performanca ot the work for which this permit it iseued V l
(Sec.3097,Civ,C.�. S�cF
v.�.
lende�s Nome lD!lA Re},M
� Lender's Address v.C.fee S vnmit Fee � � U—"C� ,
b1 terli(y Iha1 I have read Ihis applimlioe and flale lhat the issvo�ce Fee �� IDMA P/C N �
above informa�ion is corrett.I ogree le�omply with all Counly invesegonon Fee
$ c�dinantee and Staro laws relortnfl io building consrruction, ro,ai pe� !��s 0 lp!M p•.m.M
ond he�eby auihorize reprexnioiives of ihis Co�nry�o enter
� upo �hn abov - en�io e ap=r�y for Inspec�ion purposes.
� ���i.� 'V o�� � I SEE REYElSE FOR FX�LANATORY LANGUAGE .
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