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HomeMy WebLinkAbout1553 0028A 0029A (443) � WORKERS'COMPENSATION DECLARATION �� � � , . �1}iereby offirm�hot I hove a certificore of�o�,e�,� 5 f � qpp��CATION FQR BUILDING PERMIT ineura,or o cerlificate of Workers'Compe �o ur � or o cer ified copy thereof{Set.3800,l . .� 0� o. �P�„w � COUNTY Of LOS ANGELES BUILDING AND SAFE7Y Cenified mpy is hareby Eum�shed. OR APPUCANT 70 FILL IN ������' .'� v��C � � Certified copy ia filed w to ty • i �� ��t' U15� �Q, AWRE55 �ion deportment. /� � . `� 1� Date �J V APPlica cirr b h1D-:�L�/L zia �ocr.urr CERTIfIGATE OF EXEMPTION FRO WORI(ERS' � NO.OF&DGS. PFqREST COMPENSATION lNSURANGE � . , S12E OF LOT NOW ON t0T qlp55 ST. �This saction need not 6e compleled it tha permii ia for one� E q�upq hundred d011ors(t1W)or lass.) TRAR BIOCK LOT NO.� , � �nqp gppK GAGE VARCEL � I tettify that in iha perfcrmonca of ihs work fy whicb this OWNFR L � p p,2+3 _ p �ZONE. :�_...; �.)L/_�� „� T� parmit is isauad,1 ahall nof emploY any parson in art�mant�pr _ � �..� �� if� ._ /� 1 so as ro 6ecome subjetl to th�Wwkers'Compel'iiotion Lawi.'"- A���k �� "-'��r=���l �t,. �� �IATIOh15 Y /' y ' � � � �afa Applicon� CITY � a.{�t ZIP -�W I T U NOTICE TO APPIICAM7: If, oflor makin �thii-Certificata o4 ARCMiTFCT O ' TEt.g 9 NGINEER 1G GNDSF NO. �O O ��STRICf GROIIi TYpE fIRE AftOCE55EDBV O Exemption, you shouW become su6jecl to thp Worke�s' p C O N S T 1 U Componsation proviaiom of ihe lobor Coda,you mutt forth- ,�'` � /!d� /p.Q �� wl�h com 1 with wch �RE55 (5$1V� �T $q� p Y Rrovisions pr �his permit shall be � L W daemed ravoked. � TEL. Z� STATISTICAL CIASSIFICATION p�p7 Npp N LONiRACTOR �[p TP.V IN}VO. - O$ Z LICENSED CONTRACTORS DECLARATION �� ���� UASS n�. �� pyyEu.uN175 I hereby affirm fhol I am{icensed uridar provisions o!Chnpter 9 ADDRE55�� Np. (commen[ing with Section 7000)of Diviaion 3 of the Businas�ond �'" ��� SEyyER Mqp Professions Code,ond my license is in ful4 fqrce and effacl. aTr aUiS �(,�.�5 C� ��p,u VALIDpT1pN Licanse Number.T��/�I � 4i[.Class�� �.E�. o STOR� � fAMILOlES CHOENCEK � �. co�no�ro�lS 6LC. C0�►STiP1[G�3o�3-3l-4J DESCRIPfbtV OF WORK eF—�C..� ^�w s���� �� � /S5� A°° � � 2 3 I om exampt�nder Sec. ❑ AL1ER B.BP.C.for�his reason REPAIR � : ��27�3 pO1e; USE Oi ❑ f7(ISTING BLDG. DEMOL Signalwe AvaicrwT ��� T � � HNAI �.Z-2 a OWNER-BUILOERDEUARATION VRIN7 ��N . y�� DATE q—J�� O �a� 1 hereby affirm that I am axempt from the Contractor's Litense A'� C�EL� '��O 8A7�}1�(.b �{7�j) Low fo�the following reazon(Sec�ion 7Q31.5,Business and FNAL Profeuions Code�: _ sy � t, as owner af the property, or my employees wifh Bj,�ppp� wages w their sole compensation,wiil do the work ond tbe anocturo ia nol intended or offered for sole(Section ����TY � z 0 0 2 8 A� 70d4,Business and Profeuions Cade�. ,HpVI� �t. � � I,oa owner of the property,om exclusively tontracting ` CONTRAGTOR Np. � ��� � �C` With licensed conlmcfors�o mnslrutt Ihe prajeU(Set- •.�� ADDRESS.�' .•, . ' �` �•�•'.- `�. ., - •`�-'� lion 7014,Business and Professions Code�. •t • � C�,6 S'l,(j Ll RE UIRED TOTA CONSTRUCTION LENDMG AGENCY 5ET BACK YARD HWY pgpp�INE WID7H � i^' ' I hereby affirm tlwt there is a construc�ion lendinq agency for fROM ,'L 7 �-�'"�� the performance of�he work for which thia parmit is issued P.t. �.�2�b�. (Sec.3097,Civ.C.). SIDE � � P.L. Lender's Nama �C Q C.Cj�(:. $ P.C.Fee S Permit Fee 9� ��Ref.�Y ��� � � i .� Lende�'�Address . 0 1 cerlify dwt I have raad�his applicatioe and slale ihm the Iswance Fee ���� lDhw P/C N � ��.e��7% � ohove informclion Is cwrect 1 agrea ro comply with all Counry Invs��ipo�ian F s Q Q ? �ry � 9 ordino os Staie laws relatin to building construction, j(�q , � toal fae �/ �!� �d V� f I.S'� 7.,' and he e ou�ho ise repreeen�e res�of this Counry ro enter IDMA Perm.k � -�� � upon bove• entioned pr p rly for' tion purpwot. � C�C'L���` � r , ifE�EYElSE FOR F%MANATORY tANOUAGi f '.`�' Slqnolun of Appliwnt or Aqenf poh N �� _s c, S .. . - � . ci �� O � ,C, y ,xn� � ' , .'�`.. L "6^� ��3 � _ .. C+ L 'y3 .r..' � � l.I ., v .. 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