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HomeMy WebLinkAbout1552 0025A 0026A (441) � � 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(SiW)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�REu � . W. � S•rQ�T- �U���CIa � bRCIY1l �/ �� so os to become avbjxt lo tha Worked Compensouon 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: exi5nn�etnG. oEnw� �j.36 • 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 mle(59tNoe 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.esrgori n Fee � ordinanca and Slate laws relati to bvildin construcfion, f / y� � �_ ond he oulhorize repre vos lhis CouMy to enter � `���� � Towl Fee ,(O 7� IDMA Perm.M Q �'�'`'�•� " � � upo a bove entioned pro or I specflon ur oces. - ^ P P. � , -� _. , - � . 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