HomeMy WebLinkAbout1077A 2406A (5) I .� WORKERS'CO!.1�ENSATION DECLARATICN
., {I here6y a«;�m iha�I hove a tenificote oF�o�,��,�o,a�f APPLICATION FOR BUILDING PERMIT �
insu�e,or o cenifita�e oi Workers'Compensation Insurance,
or o cerrif�ed topy rhe�eoi(Sec.3800,'toLb-.,C�,.��/ COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. 3 � Company .Q(�LCr7.�I/X-G�
Ceniiled co �s hereb furnished. BU!lD'NG �O�O ���'
PY� Y FOR APPLICANT TO FILL IN
ne�:ess
Cernfied topy is i�led w�ih ihr.coi my build��g inspet- BUROING�
�ion deparlmenf. � AQCRESS�O �
Da�a �� � Applicanl � C�TY ZIP LOCALITY
CERTIFICA E OF EXEM.PTION FR0�15 WORKER ' NO.O�BL�GS. NEAREST _„�/
COMPEYSATION INSURANCE S12E OF t01 NOW CN l0T C4DS5 ST. dit./�
(ihls secrion need not be complered if�he permir is for one n55E550R
hu�dred dollor5(5100)or less.) TRACT BLOCK � 1LOT NO. /y,qp gp� 7AGE PAGCEL
d�77L -[�GAIK/NO. USE ZCNE �P
OH'KER ,.7�'
�terlify Ihal in�he perlermanca ef ihe work for which�his Np. —
permil is issued,1 sholl nol employ ony pe�son in nny manner qeCaE55 3 ' �G� s �'—I S�ECiai
fo a�l0 6etome subject to the V/orke�s'Compensalion lvws. � COh�DiTiCNS 0
Da�c Applicani � W• `^ --`^^�+ ZiP U
ARCHITECT C2 TEI. �
NOTICE TO APP�ICANT: li, offe.r making Ihis Ccrfificale of EhG'NEER ��.' NO. 7�J�0 DiSiRiCT GROUa tt?E FiRE FROCESSED BV p
Eze�ption, you should betome subject to ihe Workers' COh�,� 20'�E F
Compr.nsntion prov�s�ons oi the Lobor Code,you must forih• aDCRf ���,� � d r/� � V
iih comply with such provisions or ihis permit shall 6c �-'�
deemed revoked. T«� STATISTiCAL QASSi�iCATICN p?T. [ ;pp, �"
covrencroa No.�G7-17�v ' / cn
IICENSED CONTRACTORS DECLARATION �y ��� QASS NO._Y1_D152LL.UNIT$ Z
I hereby alllrm ihof I om licr.nsed under provisions o}Chapler 9 AD�QESS �f�,5Q1�Ll�K� No. `02�3n�L
(commentin7 wiih SeU�on 7000)of Divis�on 3 of the 8usinr.ss and ��� � SEL'.'ER A'AP
Pralessions Cod�,and my I�cense is in full ferte ond e!(ect. CITY�• C1Llilr.rV CLASS e� � VAIIDATION
�� 3oa �� Sp.FT. NO.OF NO.OF CNE�K
License Num r. � lic.Clots SiZE SiC7IF5 FA:!'LIES ON,
p a/ �y �ESCR!PiICYOFWL`PK hEw � VALUATION �`
Conlratlor �1 Dafc n' ]'X� ADD � s � b�0 �
�I Om F .m�l Un(fP�SP[. w�� L ALTF2 ❑ , �� �7.7;�
B.BP.C.(or this reoSCn REPA12 s
Dote: USE CF O :'+ • • •��
EXiSTING BLDG. CEMpI
s�9�ow.� A�PLICANT TE�� FINAV7 I • .11 3 5 0
OWNE4�BUILDERDECLARATION IFR'NT� A f. n0.�(✓1_/Z7d pAT�c��j
I hereby nFfirm Ihot I om exempllrom fhe Controclor's Lltense ( ' " ''!��J J�
� law fer�tin loltewing reason(Section 70JI.5, Dus�nese a�d AD:�E55 3��s l..0 2�n�e��„h-1� FINAL �i v_(,�A,']
IVrofessions Codc�: � h, dy
OBU��Ci4G
I,as owner oi i!,�preper�y, o� my employees wi�h aD.,RESS
wa;es as thr.ir scle compenso�ion,will do ihe wo�k ond �
the s��ucture is no�i��ended or efre•ed for eale�Secfion LOCAtITY
704a,Bosiness and Prefessions Ccde). ��.OvihG �--��;;.�-iEl.��
� I,os owner o1 ihe property,om e�tlusively contracling COYTRACTOR 'Np.
wiih Ilcensed cano-ecters ro consvuct thx proicct(Sec- qo�aF55
�I �ion 70<a,Bvsiness c�d Professions CodoJ. . . .
REOu:4'D IOiAL SEIcACK� I ."!p 4 Q 6 A
CONSTRUCTION LENDING AGENCY 5E1 BnfK YARD HWY PRO�'.l�hE W'DTH
I I hereby affirm thot there is o consrrucrion Iending agency for f:tLvi • ,
I �he perfarmanca el the wa�k fo�whith Ihis pe�mit is issued p,l, • • •
� ($et.?097,Civ.C.). S��E .r
P.L. , 'Y�1 I6 •G1.7J
Iender i Nomc �" '
..'��` \., .
�I��7.r� lD";,T Ref.N - ♦'� �1 :'` � e �O�.7 J t`r
= lender's Address P.C.Fee S Pe.mir Fee �'V . ; �
� I cerlily Iha1 1 have read Ihis ap�licoiion and s�o�e ihai the lasuanre Fee �Q`�� lo."M P/C� I �O 7'8 7
_ obovr.inlo�motion is correc!.I agmo lo comply wiih all Co�nly Invesi�go��on Fre � /� �S
ordinances and 5!atr.lows rela�ing to building[anslruction, 70�01 Fee ID'M Perm.N
and hereby o�ihorize�epresenta�ives of ihie Co�n1y lo enter
upon+he abovc�me ' ned properly for inspr.ction purposes.
� Q-.7S J 7 SEE REVERSE FOR F%PIANATORY LANGUAGE
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