HomeMy WebLinkAbout0546A 0614A 1"10RKER5'CO:".FENSATION DECIARnT10N �
I hereby allirm Ihai I have a crrfificotr.af�o�,e�,,�SP�f APPLICATION FOR BUILDING PERMIT
insure,cr a ce.rYrficata ol VJerkers'Compensfon Insurance,cr
o ce�rf�ed cepy ihe�eof(S�c.3?00,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. Company
BUILD'NG ` l ���`
Cer�iRed cooy is he�eby fumished. FOR APPLICANT TO FILL IN ae_a[55 3n i o
Cerf�fied copy is filed with the county 6uild�nq inspec• pU'LD'NG T�n �rr � /
lion�!!partmrnt. � AC?�E.- yL /G�I.�/fJ,rj IOCALITY (t""�'s-I'Tt�� �(/
A�. /�J� KEARfSf n /
Datc Appliconl CITY IY'T ZIP / CRO555T. (�-.G.tr<�t1 ��a'�+'�
' CE4TIFICATE OF EXE:'�PTION FRO'+1�YO4KER5' /��. NO.OF RL�GS. ASSESSOR .
CO."��.RENSATICN INSURANCE SIZE CF LOT I.Z�7C�� N^vW CN LOT / .".•AP P.00K PAGE PARCEL
�This secfon need not be compleied if�he permi�is for onc , uiE ZC':E .'.a�
hundred dalla�s(5�00)c�ie5s.� rener eioeK ioT no. � �/ No O 1 -33 7 }
•�. s�euni a,
I ceni(y thnt in th. perlormonce of the work c �ch ihis C:':�ER , y��f1,s ,p �"�3� Oe'�d CC�.�oiTiCnlS �
pprmit is issued,I inll not employ o on i manner ��+ D:SIR:(;1 G40UP IYFE � F,G: P"O�ESSED BY �,J
AD�Fi55 O�O ST�E/�L�O��c7(/ C01ST.�— Jt�s
so as�o becc./.^.. o�� to thc lYc� C rr. �.i n Laws. ,/� /Q �a �/ V M1 ��� O
1 �l �(� CITY �/7� Z�P I/CS � �
D(1'1! _AFJ�Ii[an _ SiAl15Il(;PLCLASSIF;CI�IICY AFi. CCNDp. V
ARCH:TECT OR TEL.
NOTICE �O A .IICANT: If, af!e� .�x�ng in+ Cer�if�ate of FN�:r:rr� r.0. _L �L
Eacmption, u should 6ecemr. Suh�PCi i. thr. 1Y..rkeri CLn55 NO. � D�vFLt.UNiTS_ N
Comp�nsc!ion provisians cf Ih=Lobor Ccd�,yc_ �crth- AD77f55 =fl•�!k r.'.AP
i�h co�+ply wiih such prov�sions or �his p�r��� shall be —
deemed revoked. v �- ��" eK. �, VALIDATION
cevTanct e FS! w.
LICENSED CONTRACTORS CECIARATION
I h�mby o(l�rm thc�I nm lic�nsed�un<1=r provis�ons o}Chop!rr 9 AD�RE55 �O. yA��
�comm>r.ung w�ih S^Ulon 7000)of Di�isicn 3 ot rho Cusiness nnd ii�
Professions Codr.,nnd my licensr,is in full forcr.end r.Hecl. CITv CLA55 5
S().FT. , h0.CF NO.OF CN.ECK
License Number L�t.Class SiZE (70 StORiES Fn:1It�F5 CN�
n���� ❑ S
Conlro^.tar po:^ D�SCpIPTI V OF WCPK
� I am e.emp�From�he I�censfng requirements as I am a /) �/ /�e.�� �C� � =:���I.6 n
licensed crchi�etf cr o re,r��s•ered profess�onol eng�neer AITER � FI��AL �1 �
acling in my prc(essionol ccpntity (Seciicn 7051, '��Ai� � DATE T �;� �� �l• e . •2 j
Business end Prefessians Ccdr.�. USE C� � �«,�� FINAL
Fxi5lir:G fi1DG. ❑ By I • •J 2.H O
Lit.cr Req.No. Dale � n�•��e vT1 K�'�-� C�^�S n0. 3 ' J���C�
01"J1JER�BUIICER CECIARATION � �r ��� �
I hrre.by�f(irm ihot I om e.empi irom rh�Controctor's License q��pE55 Q � EC��£ 1 � �.� �"�7�
Law(or�hc following rcason(Seciion 7031.5,Business nnd
Pr ss�o�sCade): �.�;��,;
P.J:1 D.4G
/ I, ns owner of thn �,�eperty, ar my r.mployee.s wiih pli,^,efSS
woges as the�r scle compensa�ion,w�li do the wcrk ar+d �OCnLiTv
ehe so-uaure is no�inicndcA or cfierr.d for sale�Sec+ion
7044,Busin�ss and Prcfrssi�ns Ccdr). .•."Ovi!.G iF�. "
� I,os owner o(ihr,properiy,om evclu!ively ton'rocting CCNTRACi04 NO.
with licensed conimcte�s to construct�he praject(S�c- A�:R�55
�ion 704d,E�usiness and 7r�fPssio�z CcdP). ' r�6�.4�
PF(;UIRE'� 10TA1 SFIEACK iRC'.'. �X�ST.
CONSTRUCTION IENDING AGENCV SEi EInCK Yh�� ��'�Y FFC?.unE tV'nfli `
I herr.by nfhrm that�herr,is a canstruction Ir.nd�ng o�=nry fer � p;���;� ;;� � � ��1
�he p=r{ormance ol�he wnr4 fn�which�his p=rmii is issued �l :
(Sec.3097.Crv.C.I. S�cE �
P.�. �.. .[i 9.5 0
Lender's Nome
8 " P.C.Fee S —tt� r,.,m��v�� 1 .�C9 • • •q 9,,ri 0�
� Lendcr's�ddrrss
? I cenify Ihni I hov�rcad ihis r.pplim�" and s!ctc thot ihc �,�� �v ,,,,,��p,,.,, � � �'� b-8�
.' cbove inlcrrnaGon�ccrrnU.I agrer�,mm ly wiih�II Caon�y i.,,,ps��paano ree �
� ordinonces nd 5� tc Inw lo!ing o bu ding ccnYruU�on. Tc�ol Fnc �"' ��
ond her ouihc ize r • .srn�niiv�s o� his Co�ney to entc�
Qupon o .ve-r en' prcpert Gon p� poses.
`a � / �� I�' / � SEE FEVEIISE FOR EXPIANATORY IANGUAGE
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