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HomeMy WebLinkAbout1553 0030A -' WORKEkS'COMPENSATION UECLARATION �� J � , . -� �e,abY affirm that 1 hove a�a.,� , o�o���o a APPLiCATiON FOR BUILDIiVG PERMIT insure,or a certifica�e of Workeri om n tio nsusa ce � o�rq�ce �fied copy Ihereof(Sec C . /y� p�� q COUNTY OF LOS ANGELES BUILDING AND SAFETY Poliey�y`a/11�,�pFnpany . ❑ Certified copy+s��t �: d ' . FOR APPLICANT TO FILL IN BUILDING /� � ADDRESS �[ � /UA • Certified copy is k it e u d B NG ^� �1 ,1 f tion depaRmeM. ADORE55 'J �/ y �� 7� �� � DcN `�f I-9J APPlicont Giv DA11� $A��2- � z�P toCaurr CERTIfICATE OF EXEMPfION EROM WORKERS' NO.OF BlDGS. NEAREST COMPENSATION INSURANCE SIZE OF l0T NOW ON l0T CROSS ST. Thia seclion ne�d nc1 b�com tet�d if ths rmit is ftt one Q ��� hundred dollafs(5100)or IBSs.) � TRAtt -1 BLOCK LOT NO. � /�qp gppK PAGE PARCEL iEt.�l1i US�.I.ON.e.: J OWNER � �GL GO NO. �j�ID�. - ��' ��/ � 3 I certify thot in ehe performance of the work for which this ' NO. "���x�t =3 parmit is issuad,1 ahall not employ any person in any mannm �D�� _.� �1 ST ��l.n SPEUAL � - , . . O, w as to become aubjec�ta the Workers'Compeneation Lawa. ��� � CONDITIONS �8 2— cirv I.aS-Ai•� �t�'si G► iir -19D4t� v� Doto Applimnt � �� ARCMITECT TEL. NOTICE TO APPLICANT: If, after making this Cenifita�e of ' �� � 7Q�' WSiRiCi GROUv tvPE FIRE PROCe55Fn BY O ENGINEER E�emptfo�, you should baeome sub�eef �o ehe Workers' �t( e� �� Z V Compenwtio�provisiona of the Labor Coda,you must forlh- qDDRE55 qi� F� S , �O. � � ld•d7 �-Z. � W with camply with such p,avisions w this permit shall 6e �f� ��"� p,' deemed revoked. CONTRACTOR �L- �O��Q�.r.Np. 3 ���$y� STATISTIG4L CtASSIFIGTION A7T. , fn LICENSED CONTRACTORS DECLARATION �'r Z �y� �rc, C1A55 NO. OWELL.UNI75 I hereby oKirm Ihol l om licenaed unde`provisions of Chaptet 9 ADDRE55�1� {j.�r * � #��O Np, $EyyER MAP (commancing with Sedion 7000}of Division 3 of ihe Busineu and A ���_ Profeasions Code,and my license is in full twce and eifece CITY !+N E � MSS y��ppT� Sp.fT NO.OF NO.OF � CMEGK �. �'. Li[ense Number ��1�S� �i�.[�ays � 52E STORIES � FAMI IES ONE Icow �.��c7'ro�/ S-3/-�'0 � VALUATION � # /S33 GonlrOCtor �1e DESCItIPfI OOF W� ��D ; O O� O Q 9 ApD b �I am exempt under Sec. ��� ALTER � 6.8P.C.for this reason � f REPAIR ���yr�� Oofe: U�� � EXISTING BIDG. �� ❑ Signature APPLICANT TEL. FINAL 1�r�- OWNER-BUILDERDECLARATION PRINT NO. DA7E l0-31-4o y'� t herpby affirm�Mt J.am exempt f�cm the Convactar.'s Licensa Law for the fo�lowing rcason(Settion 7031.5, Businesa ond /+DDRESS FINAL Wofassions Code): i� Q . _ 9U�LD�NG . I, as owner of the propany, or my emp�oyees with,�, qpot�SS • ��•' �C L�r,�, wages aa their sole compenwlion,will do the work ond�� . �� the structure is not intended or offared for sale(Section ��1t7Y - - -. - �� - � , � �. � � _. 7614,Buairtess and Profeuione Code).- - MOVING TEL � h P f 3 °c� � I,as owner of fhe property,am exclusively com�aSt�29 C TRA6TOR •� : ' NO. � .- with licensed conhae�ora�o tonstruct Ihe projecl{Sec- .. ` '",•�'°�-' ... ���,. 1 r"��•i. 2 z�5 3 2 1 3 tion 70d1,Business and Profeuiona CadeJ. ADDkE55 , � `^ REQUIRED TOT.rLL SEtenC[ �G:,v C ' �_ CONSTRUCTION IENDING AGENCV SET BqCK ��� �WY PItOP.LINE WIDTIi I hereby affirm that there is a construction lending ogency for FaONi � �.C c<`U G the performance of the work for which this permit is issued V.L. (Sec.3097,Civ.C.�. SIDE v.t. Lender's Nama h�, , IDMA Ref,tl m lender's Address P.0 Fee E Parm��Fee aC ' � I certify that I have read fhis applicotion and stole thal the lssuan<e Fee �3•�� LDMA P/C M pbpve informolion is Fwrecl.I agree to tomply wilh all County �nveatigation Fee ` �r ardinan s and Sta�e laws rela ing to buiiding con:truction, Toml Fae D 1;y and 8 by authorize repre al�vea ot fhis County fo enfer �v�•/ � ���Perm.M � up e abo -meMioned p pery fo " spedion purposes. � SFi IIEYFRSE fOR F7(PtANATORY LANWAOF � Signalurc of Applicanf rn Age� Uota '"�`v� ,. � .. . � - - � «: �-'- v w � � c, k u � :.c � ti . �; � � � �`�. � ''� c � �� = E e S,,� " y �.; � r. • "�� t r+ ^ ;- '� p :u � ' : � �.�. � ''1'-'- . p � r� � " ,�' k � ` '�s i y O zs�, � ^ 7 :. ^ti ;'.�� tl N ��"��c �'t ;,-� y S �y' �- G .. i,, �� ... C ti'G i. � � ' �'s. 1` � L p � �� 7: � C � u � s' G�� U �...+', ✓. c e h : v � a^`�..'. ��^��` 0 3<n-` ..'^. "' '��•^. F '. o'x �,�."� a r ,J. 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