HomeMy WebLinkAbout1027A 2066A 2067A (5) �
�NORKERS'COMPFNS�TION DECLARATIOY � �
I hr.reby ailirm thal I hovc a trrlifitatc of�o�,e��,o,P�F qpp��CATiON FC?�it BUILDING PERMIT �
insure,or a tertilico�e oi Workers'Compensn�ian Insuronce,
or o fif�d co y h�e?}f( �c�. 8 ,Lab.C.) n�,,�^ n
Policy�No.���'��`" tompany h eQ O �,�"',1 l�/`, COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ BUIID;NG �� /V _/
Ceriified copy is hnreby iurnished. FOR APPLICANT TO FILL IN aDCaE55 (�� •e-i`'�
� Ceriified copY�s filr.d wiih iha tounry build�ng�„sne�- eu�ioiNc / ,` ��
��on deparlmenf. aD0:E55 �(� 3� STe�ale ulC IOCAtiTv f�-
�7 / �EAREST
Da�C Applicanl CITV 1�1 N ON� V<<�"'� Zlp �I�G S CRCSS ST.
CERTIFICATE OF ExER1PTION FROflI WORKERS' r10.OF BlDGS. ASSf5504
COMPENSATION INSURANCE SiZE CF LOi NOw Ov LOi l.SAP BOOK PnGE PARCEL
(This seciion need not ba campleled if iha permit is for one u5t Zo!.E ��✓+? Q Z—3 3 7
hundred d011or5(SI00)or ICSS.) TRACT 9!OCK lOi NO. NO.
!� ¢�. sveuat y
I terlify Ihal in the prrformance of Iha work for whith�his ov+Nt2 �r• �y- ����2 NO. CC!JDITIONS a
permil is issucd,�shall not employany pr.rsan in ony manner R /� n/ U:STR�CI GROUP iYi'E FIkE PROCESSED HY �
sa as l0 6r.come subjecr to the Workers"Compensation Lows. ACD:FSS )L� V/�eµ �4 A�✓ r-t ' 1� _ (� �Oy�� ZONE �
I�, 1 1!,\_1�
CITY V C3 LWI ZIP �J,� � �LX�St� �
Dale Applicanl SIATRiICAL CLASSIFICi41iCN APT. CON�, �—
NOTICE TO APPLICANT: li, a(ter making Ihis Certifica�e of �RCIiITECT OR TEL. q/� V
Ezemption, you sho�ld become subje.0 �o ihe Y/orkr.rs' FNG'n�E[R NO. C�a55 h0.=��VrELL.UNITS_ �+�
M1
Compensatian provis�ons of ihe.Labor Code,yov T�SI forth• pDCRE55 :EY;ER MPv �^
with comply wiih suth provis�ons oi this permit shall be / L.� 7 TE� --
dertmedrevoke.d. CONTRaCTOR l�• /�•�I!.� �II�Ir No.S`7`/-�f�G aK. PG, VALIDATION
IICENSED CONTRACTOR$CECLARATION iiC.
( I hereby af(Irm thnt I am licensed under p.o��s�ons of Chop!er 9 nDORE55 ✓r„h C NO. Z /0 7 VALUATION
(commencing wi�h Setlion 7000)of Division 3 ef Ihe Businr.ss ond ii�
Professio�s Cod^,and my licen�e is in full force and eftecL �iiv C�n55 a � 3 U��
3� /O !7 1 50.Fi. NO.OF �,;�,CF CHECK ,
ticense Number 7 � Lit.Class �� � SRE ��S� SiCe'ES FAMqlES 04'E n 1 O�.7"
S
CfSCR'PTICNOF WORK h� ❑ ��� �� �.�3
CO���OCf01 Dn�r '. • • •
ADD
�I am exempl undrr Sec. ` ��� � �LTER � FINAL 1 � • •2.�..Q�
6.8P.C.(cr this recson RFPAIR � DATE /��}�� � � �
•C..CC�
Da�e: USeC� CEh+.OL � FINAL i` ��i
E%ISTING 9lDG. By Vl G 6 2 8—�S
$i9nature AORiCANi TEL.
OWNER-BUIICER DEGIARATION f�i4T NO.
I hereby affirm thot I am e.empt(rom�he Contractor's License ,
law}or ihr,follow�ng reoson(Sec�ion 7031.5,Dusiness and ACCc¢55
Professions Code): ,aE.Ehi �
� eunnr.,c
1,os owner o(1he��operly, o� my employarts wilh nCD�:55
wo9es os thr.ir solr.compcnsaYon,wili do the wcrk and �2 G a 6 f�
ihe slructure is no�in!ended or ofFrred for sale(Sec�ion lOCatiTV ' '
70«,Dusiness and Professions Codc�. �A.OViNG TE�. • ��• • • •2�J
� I,a�awner o�ihe properry,om ezclusively tonhatting CCNTRACTO4 NO. �
wiih litensed wntraclors to consirucl tho prnjncl(5?0 � ' '� a G�
lion 70�4,8usiness and Professions Codr.J. ADDRE55 . .
RE(]uIRC� TOfAI SE78ACK FROM EXIST. � � 3���
CONSTRUCTION IENDiNG AGENCY SEi AACK vaao �iwr pq�p ��N� w:orH �
I hereby affirm ihoi lhere Is a consiruction lendin�ogency(or f�EUrli Q$,0']—�j 5
�he performnnce of ihe work for which lhis pe.rmit is issued P I
is��.3ov�,e��.e.�. s�oe :2 0 6 7�1
— P.L.
m lender's Namr, ;�• • • • •
� P.C.Fee 5 �S.�� Pr,rmit Fee �
Lendeis Addrese � � • •5�1 v�
� I ceriify tho�I have read this applicotion and siate that the � h,oa�ae Fe� �� . . . �S
� obovo informa��on ie correcL I agree�o comply with oil Co�my invnsngaron fee � 5•�V��
ordinances and Siote laws rr.laii g to b�ilding cansfruction, Te�al fee Q Q Q�]�'fj 5
G and��e6y ou�horize represent t ves oi this County to ente.i
� upo e above-men�ipned �ny for inspection purposes. �
� y 6-Lr_,�f SEE REVERSE FOR EXPIANATONY LANGUAGE
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