HomeMy WebLinkAbout1396A (434) , . .. _._.:_-_----= ------- -- ------
' WORKERS'COMPENSATION DECL4RATION - . . -� .
I hereby affirm that I have a certificote of�o���,�0 5e�f � � � APPLICATiON FQR BUILDING PERNtIT �
insure,or a certifica�e of Workeri Compensation Insuronce, �
w o certified copy thereof(Sec 3800,lab.Cj•.. .. - . _.. .. ... ...... ... .. ...___._ _-_._-_..__.__._. ._ .-_..._.._
COUNTY OF lOS ANGELES 8 DI AND SAFETY
P❑ol�ityNo. Company r`/g�el s �i,
Certified.copy rs hereby furnished. FOR APPLICANT TO FILL IN Bl11LDING , `` O /�u�
� . , AOORESS � U/ L7
Certified copy is tiled with ihe count bu Idin9 inspec- Buit ING f•,� 'Q� � �`
fion�depnrl M.•.. ADDRE55 W 3S Wi vw
ppte'. � � V AppliCaM �"� CITV N / 21P IOCAIITV �/y L .
��CERTIFIeA7E OF EXEMPTIO WORKERS' - 5¢E OF LOT O ON8 l0 CRo�ss Si.,��N A,0 �', CQ{.��M/9 �
. ..COMPENSATION RANCE-.
(7his sec�ion need not be completed if.the permit ia for one � �� - 3 �1� S I /+��R� �' � � �
hundred dollars(S1oD�or less,� «�T `� BLOCK ior No. �,y�,p epq� P�¢ PAR�L
' TEI. U 2 E M�P / �iY
I certify Ihat in the perfarmonce of the work for which this OwNER ��e� LC NO. � NO. y
rmit Is fssued,I shalt nm em la on rson in an manner �,j, - SFEO,aI� - - � 0.
so ns to m�e}/ bject to ihe W Y ker PCp nyp On dws. ' AWRESS - ( (�C��L�� �U��� CONDITIONS 0
Dme ` ''' 8 � . .. ; . . .. . w . � V
QiY . !;'.. 1 I'y'e ...ZIP__ p�
I
�P�i��t � ARCHITEQ OR TEL. O
NOTICE FO.�.PPLI If,-after ing this Cerfificrna o ENGINEER � DISTRICT GROUP TYPE .FIRE PROCESSEpBY
Exemption, you should become ubject�to the Workers' ^ CONS/T.� ZONE �j
Eompensation provisionc of the i Cade,yoV must forrh- ADDRESS (% � 4y/y LV �
with comply with such-pravisions w-tbis-.permil sk�all be . . .._._. _ ., w
�/ � / �}p 4� STATISTIG4L C IFlCATION APT. CONDO. Z
deemad revoked. � . . - . CONTRACfOR /y NO. G �/ r � .
LI(�NSED CONTRACTORS DECIARATION�--. . . .. � t rt .�� as.SS NO. �� DWELL.UNITS
i here6y affir�F{pt I am Ikensed under provisiorn of Cfiapbr 9 AD�RESSQ/a� ��V�L� ,,�.33 Q
(wmmencing with Section 7000)of Division 3 04 the Business ond _ � E�Q Q ��C _ �� /
Rofeuiom Code,and my license is in fuli force and eifecf. cm Ctnss C"/� ��� ,�,3 VAL�ATION
/� SGI.Ff. y� NO.OF Np,pF CHECK
License Number�� �" ' lic Class ��� � SiZE STORIES FAMILIES ONE .
�/ljV�.G6�/fl. . .. .. � VALUATlOH _
Confracbr �Date DESCRIP,IONOFW�2K � ��' s aaBD D/,
�+ �l ❑ t V �
�I am exempf under Sac. J� �� • ` '�r��`��R qDER Q �
B.BP.C.for this leason qFpp,�R-0 i �
..-... .. . ,.� __,.-Doter._..., -- U5¢oF a . .
E%IS71NG&DG. �
_ Signalure ...._ ._... . ... .. . -. APPIICANi 7EL FINA� , I
OWNER-BUIWER DECIARATION .. . . ..atIN7 . . . No. � � i�I :i .�!;!;
�^^'^' _ DATF
.�..Ahetabyof£irm�hWlcupeaac+ptfrom.lk+a. �o+:slicanse • e e •�
ADORESS .` . ^a
Law for fhe following redson�SecFioo 7031.5, Busineu and FINAI
�PrOfBsslOnf Code): _. . .............. _, . .. ..,... . PRE _ . . . __ _ . __._.. _ . . .:'g�,_ ' -`'�+� /� ' ' � 4'-. __
/ a p ,
Bunouv� -'`�"
Q _I, us ownar of the properfy, or my employees with ADDRE55 _
_ _ _- ___---.__ .. ... . _......_._.._.._.._. .._.._.. .
wages os their sole compensation,wilf do ihe woiTc and ---- � � -- �� � + � � ', , � � T
�he struclure is not intended or offered 4or wle(Seaion ����TY � i � �� . �- �
. . ..7044.�Business and Professians tode).--.. . _.. ... MOViNG.._. .. . . iK. - � G..H i i —n�'�
.
i,as owner of the property,am exdusively controcting cOrviRaCTOR NO. ��,_ � �-�., .•
..�._. . . :".:-, �. .
� wifh iicensed contructors to mnstruct the project�Sec- '- - �--�-- -. ...� . ... �...... . _ . - �
tion 7044,Business and Profesaions Code). AOORESS
- �� - �CONSTKUCTION IENOING AGENCY�� �-�-- - � ��7ngq�K YARD� MWY TOT pTpBA`WE WIDTH
I hereby affirm rhat there is a construction lending agency for iRONi
��he-parformonce of�thewpk for�which thia�permit is issued - ..-- .-p.L ...... . .. ...._ . .. ._. ._.._._ . . ..
(Sec.3097,Civ.C.�. SIDE
m .... . P.L.
_... _ .__ . . _ __ .
� Lender's Name
�"- J�j � IDMA Ref.A �
. .... .. .. . . ... ._... . P.0 Fea S ". .. . ._. . Permk fee..-..._c?O�'. .._ ' _
- lender'a Address �f , .
� .i certify thot 1 have read this npplicatinn ond state.lhai_iha _._ _ .hsuonce Fee �L' IDMA P/C M
_...- --�--' ---- -'
¢ above informoiion is correct.I ogree to comply wilh all County invasii arion Fas ��Q U
� ordinpnces ond State laws.rela�ing�o building construction, �
._. . _.... ... ...' '-__.__ ....._.__... - 7ablfae'_ ' -/- '..._. LOMA Perm.M
� ond hereby authwize representafives of this County to enler
� u n f abpre-man one perty for inspection purposes.
�.\ y.,�,$
a 1/G SEE NEVERSf FOR EXPLANATORY IANGUAGE I
� �� Signnn,mvFAppficam,o.�.Age�F. _ .. ......_.p� . . .pi
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