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HomeMy WebLinkAbout0711A 2802A (6) � WORKERS'COMPENSATION�ECLARATION �� ��'"� '�1 hereby affirm Ihal I hove a certifimte of consenl fo self APPLICATION FO� BUILDING PERMtT � insure,or a certificate of Workers'Compenwtion Insurance, . a cerri da`d�co�p�y,p�h.e�eof Sec.3800,tab.C.) COUNTY OF LOS ANGELES BUILOING AND SAFETY Policy�" " ��pOnY /1/� �ILDING y �Certified copy�s hereby furnished� FOR APPLICANT TO FILL IN ��Q � ❑ ADDRESS 1 Certified copy�s filed with�he co�Ny buildin9 ins eo BUiIDING .i/D ��on deparfinent. ADDRE55 � �a1e�Applicant Cliv ZIP IOCAIITV `\ �l�C���1r� �r�s�_ �RTIPfCATE OF EX N FROM NO.OF BlDGS. NEAREST ` � ����I� COMPENSATIOtJ INSURANCE SIZE OF LOT NOw ON lOT [R065 ST. S11JY_ (This sectian need not 6e cumpleted if Ihe permit is tor one - iRAR- - -� BIOCK "" LOT NO. � ��R , hundrad dolloro(EIOQ�or leas.) Nu1V BOOK CAGE PARCEI .. 7E1. ZONE h1AP I certify thot in the performonce of the work for which this ��R N�O�� �� permit i5 issued,1 ahall nof employ ony person in ony manner `��p� � so as to bemma subjad ro 1ha Workers'Compenwtion lows. ��� / ���T�� � CITY p ZI7 � Date Appiimnf ARCHITEC7 O 1EL. .' �TICE TO APPlICANT: If, afier making ihle CmRificaro of � DISTRICT GROua irpe ZRwEJE VItO[e55eo ev O \ :mprion, yov shoold 6ewms wbjad fo rh� Wwkeri ENGWEER o. _�. � ,(� CON�,� Compen6ation provisions of the L06or Coda,you muzt forth- qppRE55 O .�1 ��Z `� l� ��" 1 (�C W with comply wifh such provisions or this permil shali be . TEI. S TICAt QHSSIFIUTfON AGT. CONDD. � deemed ravokad. cowrRncrat np — n� Z LICENSED CONTRACTORS DECLARATION ���, f1A55 NO.�DwEll.UNITS �he�ehy affirm Ihat i am licenxd under ptovisions of Chop�er 9 ADIX2E55 NO. (commencing wifh Section 70W}of DivisioN 3 oF the Businas3 a�d LIC. '��R� Professions Code,ond my licenae ia in fuli forca ond affect. CIFY -�i CtA55 '� BK � YALI�ATWH �.f $p. T' NO.OF �J NO.OF CME K Li[ense Numbar a,���� Lic.Claa' ,�� SIIE S70RIE5 (r FAMILIES ONE VAlUAT10H OESCRIPTIOIJOF WORK �W �o�,�,o,T%�,�� s,+Ir�o,a � s 1`a.�c�c� p Terw,-►k rrr+ oF . "°° � I om exempt undar Sec. � A��R � ��7L� A 8.8P.C.for thia reaaoo �xLS REPAIR - � lJSE Qf �'. e?v D f6: E1fI5TING BLDG. ' �E� � � • - s�g�ow.a nrvuuNr. � a�3 pwu C I •5 C 3.6 3 WNEp-BUILDER D �iNi 1 De5 0. Z 6 DATE �!.�z,,�ip 1 hereby affirm thet I am ezempt r m fhe Mractar's Liceoae � " �" " " � �"� � "� � � "�� �� � 't Low for the following reaeon(Section 7 I.S,Buainess and ADDkE55 pNu �--� • c J C�"�,`:`'' o�of��a��c�ar R �y o�.o G—�� � � BUIIDING 1, as ow�er of the property, or my empbyees with n0OrsE55 . woqes ps their wle tompensation,will do ihe work and Ihe shuclura is not intended or offered for cole(Section �O�AUTY 704A.Business ond Professio�s Code{• MO��� i� . - .. � 1,as owner ofi the property,am exclusively controcfing CONTRACTOR NO. wi7h 4icensed contmclan to conatrucf!be projrcl(Sec- ADDRE55 tion 7041,Buiiness cnd Rrofess7ons Code). CONSTRURION LENDING AGENCY 5�T B qK YqRD HVJv 707AL�tvB,4`INE wIDTH 1 hereby affirm tha�there is a conslruclion lending agency for FRpry7 z 2 8 0,2 A the perforrtwnce nf lhe wwk for which this permi�is issued v,L. ��� � � �� (Sec.3097,Civ.C.). SIDE P� I ••60,OC lender's Name O lDha Ref.M I •�4��� m P.C.Fer S Q P�rmir Fw ` Lender'a Addreu (��yf � I certify that I have read this appliention and slWe IhW�he iaauonce Fee IDMA P/C N v 1 1� , ••6 C 3.;�� � o6ove informotion i�cortetl.I aqree to comply wilh all County Inresii otion Fee �y � q ordinontea ond Slole laws relating to buildinp conatruction, � Tom1 hs a 3 � IDMYA Perm.k�0� � �.��—�8 ond hereby authwizs rap�asentofives of rhis unty to enter � � upon the above-men�ioned p pe ty for in etion purposea.�/ \c'n M O O �(�mw e�s.O G � _�/ ��D d�>]�•� J .l fFiRiViNSE/OREXPUINATONY UNGUAGi Siynatura of Ap �ate .-- ' � .- . _s y s , • u ^ y `� O 4 y � � j � w o - � ~ .�M..�... �'�i. -�t..; " �j � . , 4 J . v.,3 O C cr 0 � � �.+-.�' p; , i . t�a c �� � w °i � � w � yM a � d � � " .�c y= 3Qa M� �,z H� o � _ oc � � � ; c,Xx �� �s ,.: �� r�.~ ' - � Y. �� � `� °`� L-w'� C! w . v.r. v f: h�- .m �n•L s 1 "M N C� � ,C Y • '� .f+ v. � _' v.,�� Y` T�i ..Ni 4' ',p�'y`�--"'�"��•�'�" � ''�'� 4. � � O'� �'.�'.. 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