HomeMy WebLinkAbout1797A V�'ORKE45'COV.PEhSATION DECLARATION �
, �=reby alfirm tha� � �av�a«�,;f;�a�e of�o�.e�„a.�,f qpp��CATION FOR BUILDING PERMIT
insure,or a certili:a�e cf 1'lerkers'Cer�penstion Insurancr.,or
a cnrfifi���opy thcrecf�5=c.?300,lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolityNo. Company
� Ce�+�fied cepy�s hcreby turn�shed. FOR APPLICANT TO FILL IN �U!LDING � ��
� Cr.rtified cepy is filed wiih thn coun!y 6uild�ng inspec. 9Vi�C�t:G •)/y} ^7Z� / (/p[`p �C�>CSS �b��
f�on deport�nent. � ACC+"E55 .�LLV /L {.��//�� ICCALITY SJ ,.
�E�F(ST �� �r
Daie �rpl�cam aTv ���D�/z ,a�r0 zia CeO555t.
CERTIFICATE OF EXEh+.PTION iR01.1 LVORKERS' No.CF E�LCGS. n55E55C4
C04tFEN5�Ti0N INSURANCE SiZE OF LOT Noa�Oa�Ot l.`AP P.CCK PnGE PARCEI
�This srclion need no�br compleled if�he permi�is for onn / i IU'.! a+.q: t�
h�ndrr.d dollars(SI00)or less.) iRA�i ntGCK LCT n0. �1 NO. f d`�. ,� 1 r
Q iEL S.FCiAI � a
I ceriify that in the per(ormance oi ihe work for which ihis ���'��R �" -S�Q NO�q�-� 1-(� CCN�ITIGtiS Q
r�il i5 i55ucd,I shall nol Pm IC n �'���+'CI GVCUP IYft F!RE f70CES�E��Y
P^� � y y p^�son in any monner qppqE55 �� CONST. Ip��e V
so es io Mcome sub'r.ct to ihe Worke�4 e�.r�sotien tq.ys. � C
3 �' n -�����.. urv `� ziP CZl � � '��c��i o
Dnrr._ npplicam ry �lGf� :f/�IIpI!CALCLP55'FICAIiOY n�r. coti.�o.
—I NOT� � AFPL CANT: If, n(ier moking rhis Crrtifico�n ol �RCHiTFCT C� iEl. w
fze.T.p!ion, yoU shoutd becomr subjrCt 10 thC �YCrkerS' FM1(�!\�FR Np. CLASSNO. D':':ELLUNITS_ a
Compensa��on p�ovisions o(the labor Ccde,you musf torth- y
iih comply with such pro�isions or �h�s perm�t shnli l;r. �C:pE55 SEw:u:�n�� z
d^�m�d revckr.d. � / TEI. —
LICFNSED CONTRACT025 DECLARATIOY CCNi�nQCR i ti ,�,.Z��4n033a S75 FK. �'G• VAIIDATION
I hereby allirm�hcl I am licensr.d under prov�sions of Chnpirtr 9 ADC7E55 / ,(� ���� • � 0
""" � ��0• VALUATION
(commencing with Srtcbon 70W)ol Division 3 ef thn.Bus��ess ond �/-'^ Q '�G
Prnfr,ssions Cod�,and my Iicense is in(ull force nnd r.ffecL CiTv �CCCI / � 2[/.�/Ctn55 d/ S
.> SQ � . NO.CF h0.OF CIi:CK
icens^Numhrtr Lic.Closs_�_ Si2E STO�!ES Fn!t.iI�ES C!:�
Conlrocbr , q' y{�p�p_��'`'`_`� CESCRICTIOV OF LVCR¢ 7�.%�} NCv! � S
I o^i e:r.mpl(rom Ihe lice.nsing requir.mr.nrs os I or�o , �
LL�l—eh_ c � C✓,�vtL ^eo
-. Ikens�d nrcharc�cr a regis�e.ed pro�=ss�o�a1 er^ineer n!7ER � FINAI � // �� �
e;!ir.g in ry prcless:onal ccpncity (Seciien�7051, � y DATE �p � .
Bus�ness and P�oless�ons Cede). ' _ �`-�a'R ❑
USE O� � FINAL
E%�ST'NG°LOG DE:'pL
Lic.cr Reg.No. Date ACPIICA'�1 /� TEI. BY � _' �'`'�t
OYJtiER•9UIlQER QECIARATICN fPp�tiT) � ,��1p, �/
I h?reby affirm ihol I om r.zempl frem the Conhacler'S Licensr
law icr ih=following�easan(Seciion 7071.5, Bus�ness ond ^D�:[55. � ?? (Q��
PfOfl!SSiOnS CO(I!:�:
OBU::UI!.G
I, as owner ef the prcp^riy, cr my employers wilh pC:;cE55
wo�=s os�Feir solr.compenso��cn,will do fhn,wark and _q t 7 9 7�
the s!ruclure is nol i^!=nded cr cifered fer so�e�Sr.cticn lOCnt�TY
.704A,Cusin�ss on�1 Pro(essions Code). , .a•pV�NG TEL. �l� � � � �.,
� I,ns owner of ihe p�operry,nm e.dusi��ty con•.acfng �nNTRACTC4 no. �
with licensed con•r�ctnrs ro con�rruct�6e p•oj=ct(Sx- A^�.F55 � • �O�,J�
iion 70aa,Buslnnss and Frofessions Coda). - .
F'kL'U'GCD iOTAI SEIt ACY FRO'.1 E%ISi.
CONSTRUCTION IENDING AGENCY SEl RnC[ �AQ� H'��� CAq� I�P<F 1":�DiH ��� ��7 S O F�
I hereby alliim thot ihnre is a tons�ruciicn lending ogrtncy For �G��;��
the perfo�mnnce nf the work(o�which ihis permit is issued a� 0 3 0 9—8 2
(Sec.3M7.Civ.C.). S�L`f
r.i.
Lrtnd^r'S Name
� P C.Fcc S rP.m��Fe„ R,DO
lender's Add�rss
� �cerlily Ihat I hove rer.d ih�s appt�mi�on o�d s�o�r.�hnt ihr. bw cr.Fe� Q
Qabove in(ormotion is correcL I nprre�o comply wi�h oll County Inves��nm�on Fro � ��
ordinnnces ond$�ole lows reloting to buddmg cons!ruc�ion, Te�ol Fno � � .sQ
and heroby a horim represr.nmtives cf th�s Coumy to enrer
^ upoa J e nF r.-meNinned�'Cp�r�y for inspocticn porposes. �
/ / /�3`/
4 � � �F[�f. �,� � SEE REVERSE fOR EXPLANATORV LANGUAGE '
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