HomeMy WebLinkAbout1552 0025A 0026A � � WORKERS'COMPENSATION DECLARATIO^�L � # Z
'�� � APPLtCAT10N FOR BUILDING PERMIT �1
� • � hereby affirm that 1 have e i con��lf
insure,or a cenificafe of W ka s�a pe ation ns ce,
or a cenified copy�hereof(5 c. b. .) �
�c�Q �� . m � COUNTY CF LOS ANGELES BUILDING AND SAFETY
�v � v
Cerrifi �py i he■6 r BUIL�ING �3 Q 91 n!_ ,¢
❑ �` �/� '� EOR APPLICANT TO FILL IN qppRE55 !/ f/�.r�„ �ti •
❑ Cerfifi P CFpy�i�il�� 0 � � ins BUIIDING /�� ,1 ��sr� D�. �s
rion ds arinc/�� r� ADORE55 ! v r
l.iT � �
oore�ap�,��w�r aTv�/AM4dJD ��2 CJ� nv � �ocnurv
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BIDGS. NEAREST
COMPENSATION INSURANCE SIZE OF l07 NOW ON lOT CRO55 ST.
(This aection need�ot be tomplelBd ii Ihe permif is for one iRAR 3 /�/ BtOGK LOT NO. W� ��R
hundred dollars(5100)or Iess.) MAv BOOK PAGE PAR[EL
OWNER
rME Y_oc.L co ',,;ocuJ rsz3; u�,�o�, �
1 certify that in the performance of�ha work for which tbis � - D10. �-�.�
parmi�is iw�ed,1 shall not employ any person in any manner qD�RES$ � . (/,�. � SrQ�T ����a � �� �/ ��
so os to becoms avbjxt lo the Worked Compenwuon Lows. ��� CONDtTIONS �P S .,� �
U
Dme Applicam arr �dS-�L�nf � ��5:� � ziv-'� Cf � �
ARCHITER OR TEI. ey -��.p
NOTICE TO APMIGANT: If, after moking this Certificate of ENGINEER �iQ��(1 � . p, iI� �77- �ISTRICT GROUF TYPE FIRE PROCESSEpBY 0
E:empfio�, you shuuld becoma subjec� to the Warkers' �C CONST Z F-�'
Compensotion p�ovisions of the lo6or Code,you must.fonh- ADDRESS e�c.7 ���/OA.� s'r �O. PAs. 9i !'0 0 ��Z � W
with comply with such provisions or fhis permii stwfl be El j.� j�Zj--- STAASiIGtClA551f a
deemed revoked. - --- - _�T £ I�pi10M qPT. , tn
LICENSED CONTRACTORS DECLARATION CONTRAGTOR D�.l_ CDN'✓TQIdL�p�p. aq�NO. �� DWELL UNITS Z
!hereby offirm Iho�1 am licanied under povisiona of Ghopear 9 AO�RE55 (u� T"� �NO.
(commerxing with$ection 7000�of Oivision 3 of the Business atd p'' LIC. ��R�
Rofeuions Cade,and my license is in full iorce and effed. ��Ty 5 ryrv � ��{- ��5 YAL{DAiION
`, SQ.FT. NO OF NO.OF �e CHECK " BK. �'.
License Numbar T��7SI- F'a Gass� SIZE � STORIE5 � FAM�UES ONE
�j VALUATION
co�n� rA/J5TQl1 GT(a oo„ 5•31—`�v �SCRIVTION Of WORK (3Lp r�w/—' s 3 7a Qy-t7 � #�,J-�•Z
ADD �
❑I om exempt under Sec. ��R ❑ Z�j
8.8P.C.for fhis�eGSOn u�� RE7AIR f �5.�/ p
�ate: EziStiNG etDG. DEMOI `�•�6
• Signvture APPLICJWT Ta LEL�NO.�) }� — FINAL /� I�-2C G
' OWNER-BU0.DERDECLAiiAT10N PRiM DATE ������TCJ /�0�
I hereby affirm thoi I am exsmpt from the Contractor's Licansa 97t ��� �- �¢'� O�T��
low for tha followinp reawn(Seclion 7031.5,Business and ADDRESS�ih7[1 p��
Profewiorm Code): PRE E Yy
BWL�ING ��
� 1, aa ownar of the pro{»rty, a my employeas wi�h ADPRESS -- - - z G C Z,.:h
wdges os thair sole tampenwtion,will do the work and ' '�`"'" ' '• " ' '.'� � �l
�he atrucfu�e ia nof infended or offered for wle(SptNoo LOCALiTY ` ' _ ��r,� �2 3
7041,Businecs ond Profmsioes Code�. AhpwNG .J _ �. . .TEL"-. .' . -. .. ..'. , .
� 1,as owner of the property,am exclusively commcting NTRACTOR. ' NO. �1 (�'�7.'7 4
with licensed contratloro to wnstruct the proiect�Seo- .. ' .,�`�'' �"
tion 70d,Busineu and Profeaaionn Code. /DDRE55��'- �
) 1,4%7:74�
CONSTRUCTION LENDiNG AGENCY SET BACK YARO HWY T�T'�`�rROP.LINE WIDiFI
I hereby affirm�ho�thera ia a canstruction lending agency for FRONt j �:C C���
fhe perfwmance of the work fw which this permit is issued p,L.
(Sec.3097.Cir.C.)• S�DE
P.L.
lender's Nome �Q�C.�H
/ IDMA Ref.N
m lender's Address P.C.he S Perm�t fee 10 �n• 3 �*�� � ' � �
� I cerlify thot 1 hova read�his applica�ion and storo tbat the Iswence Fee �3•W LDMp,eiC M � ' �1.6 S 9,7 J .
obove information is correct.I agree to comply with all Counry In.esrgorip Fee �
ordinanca and Slate laws relati to bvildin construcfion, �r / y� � �_
and he ou�horize repre vos fhls County to enter " !���� � T°�°I F'° ,(O 7� tDMA Perm.M Q �'�'`'�•'" -
� upo a bove entioned pro or I specflon ur oces. -
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