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���`
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