HomeMy WebLinkAbout1553 0028A 0029A (445) � WORKERS'COMPENSATION DECLARATlON �� �
, . �1}iereby offirm�hot I hove a certificore of�o�,e�,, 5 f � qpp��CATION F4R BUILDING PERMIT �
inaura,or o cerlificate of Workers'Compe �o ur �
or o cer ified copy thereof{Set.3800,l . .�
0� o. �P�„Y �
COUNTY OF LOS ANGELES BUILDING AND SAFEiY
Certified mpy is hare6y Eumished. BUqDING
� Certified m OR APPUCANT TO FILL IN ADpRE55 � ���, �
py ia filed w co ty i IL ���' U15� �Q,
�ion depurtment. /� � +
`� .0
Date �J V APPlica cirv D n�D�:��42 zia �oci.urr
CERTIfIGATE OF EXEMPlION FRO WORI(ERS' S12E OF lOT NOW ON t0T �REST
COMPENSAiION IN$lJRANCE ' � , qlpSS ST.
�This saction eeed not be compleled it tha permi�ia for one� E qSSEupR
hundred dollors(t100)or less.) TRAR BIOCK LOT NO.� , � Mpp gppK FAGE PARCEL �
I Crttify that in iha performonca of ih�work fy which this OWNER L � T�jp,2�3 _ p USE ZONE,i:�_.,`, �.JL/-��
7�
parmit is isauad,1 ahall nof emploY any parson in art�mant�pr ^�� � :{a .y�„ `, if�� /� 1
so as ta 6ecome subject to th�Work�rs'Compel'ieotion lawi'"-�� AOORESS� r� -->'rJ't'r=����T -�w+t.t C% �p�ATIOhIS�Y /' y '. . , �
�ata Applicon� CITY � a.7�t ZIP -�WIT U
NOTICE TO APPIIUNT: If, oftor makin �thie-Certificata of ARCMiTECT O ' TEt.g
9 NGINEER 1L1 C/NDSF NO. �O O ��STRICT GROIIi 1YpE FIRE %tOCE55EDBV O
Exemption, you shouW betome su6jecl to thp Worke�s' CONST 1 U
Compansation proviaions of ihe Lobor Coda,you mutt forth- ��,�"� � pfQ� /p� ��
wllh com 1 with wch ADORESS (ay� ST Sy�
p Y Rrov�sions Qr �his permit shall be � � L W
daemed ravoked. � TEL. Z� STATISTICAL CL1551FICATION p�p7 Npp N
LONiRACTOR �[p TP.V IN�VO. - O$ Z
LICENSED CONTRACTORS DECIARATION �� ���� QASS rq. �� pyyEu.uN175
I heraby affirm fhol I am{icensed u�ar provisions o!Chnpter 9 ADDRE55�� Np.
(commen[ing with Sectian 7000)of Diviaion 3 of the Businas�ond �'" ��� SEyyER Mqp
Professions Code,ond my litense is in ful4 fqrce and effecl. aTr aUiS �(,�.�5 C� ��p,u VALIDpT1pN
LicanseNumber.���7�I � 4;�.e�a� f s°.e�. 0 sroR°s � fAMILOlES � CHOENCEK �' �.
ConHa[for�b� KWJI4'XG�o��7'���4� DESCRIPfbtV OF WORK 0ri���� NEW s���� �`, 7F �S5�
ADD � V V �
�I om exampt�nder Sec. ❑ Z 3
AL1ER
8.8P.C.fo��his reason REPAIR � _ /7 27�3
o��e: use a �
f7fI5TING BLDG. DEMOI
Signalwe AvvucrwT ��� T � HNAI I,�-2
OWNER-BUILDfRDEUARATION PR�NT ��N . y� DATE q���� O ���
1 hereby affirm that I am axempt from the Contractor's License A� G�EL� '��O f�A7�}�l.b �{7�})
Low fo�the following reoson(Seciion 7031.5, Business and HNAL
Profeuions Code�: _ sy
� t, as owner ef fhe p�operty, or my employees with Bqppp�
wages w their sole compensetion,wiil do the work ond
tbe anucturo is nol intended or offered for sola(Section ����TY � z 0 0 2 8 A�
70d4,Business and Prokuions Cade�. ,HpVI� �t. �
� I,aa owner of the properfy,om exclusively toNracting '�� CONTRAGTOR Np. � ��� � �C`
with licenaed commctors ro mnslrutt Ihe projeU(Set- �\ ADDR�`55.�' .•, . ' �� �•�•'.- �-�. „ - ••�-�,�
lion 7014,Business and Professions Code�. •t • � C�,6 S'l.(j U
RE UIRED TOTAI
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 Ihia parmit is iasued P.L. �.�2�b
($ec.3097,Civ.C.). SIDE � �
P.L.
Lender's Nama �C Q L.Cj�N.
$ �J 7 IDMA Ref.Y }'�i � a s �
Lende�'�Address P.C.Fee S Permit Fee .
o t cerlify dwt I have raad�his applicatioe and slale thm ths Iswcnce Fee �3.� �p,Hp,p��{� � ��.���7;
° obove informalion Is cwrecf.1 ogree b comply with all Counfy Invs��ipoiian f s Q Q ? �ry �n ..
q ordino et State laws rolatin to building consfruction, j(�q . � toal f a e �/ �!� �d V Q F �,�"� 7� �
a n d h e e o u�h o i s e r e p re e en� e s�o f t h i s C o u n ry ro e n t e r I D M A P erm.k � --�
� upon bove• entioned pr p rry for' tion purpwot. � ��C'����`
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ifE�tYElSE FOR F%MANATORY tANOUAGi f '.`�•
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