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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'����` � r , ifE�tYElSE FOR F%MANATORY tANOUAGi f '.`�• Slqnolun of Appliwnt or Aqenl poh .. S..�Q y� � _...T Y ti:. �N .�, � � � p ~.;. =�` � C O �- y „ C C C V �. ' .,... . v���r. :�� i. � C c' F " �C �i � O » � y S c,F o. .O u � t, U � ' . i:.,��„ ^�n ' .. . �C y � N y N CV r '�^ �y" y `,1... ?v`,. C:': .i� = w H r-�c C y'�o e C":' � m . 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