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HomeMy WebLinkAbout1326A 1327A � c�,1 ��L�5 ��z. WORKERS'COMPE��ATION DECLARATION �� � nB,eeY aff;,m �ha, � ha�E o ceriificaie of�o�=e�,fa=e�f APPLICATION FOR BUILDING PERMIT insu+e,or a certificate af Workers'C�mpenstion Ins�rance,or o certifled copy+he�e 4(Sec.380�,lob.�C,)�� COUNTY OF LOS ANGELES BUILDING AND SAFETY - Policy No.'��Company '�'� � '1� � Cerrified copy is hereby furnished, FOR APPLICANT TO FILL W ooaess ��[l� � �N�'"�'���fl �a � Certified copy is filed with!he county building insper BUILDING �11'.� w �� �� �OCAIITV �\�}Yl'�d'� '-"" � tion depPr}mepl. AGDRE55 �� D���Du zlp NEARESi Date �"���8� Applicanl � CITY ����os CROSS ST. +,z.��;�.. �l.t��r,+-�y� CERTIfICATE OF EXEMPTION FROM WOR ERS' NO.OF BLDG5. ASSESSOR COMPENSATION INSURANCE � size Or�ot LD�X Z'S ivOw oN�oT � N�n��ooK Pace PARCE� (This seclion need not be tomple�ed if Ihe permif is for one USE ONE MAP r-� hund�ed dollars($100)or less.) TkA�T `3���C�� gi�cK tor NO. ,�/ Ne. //'�.� J y iR.�E''�,QS�Y1� rEi r1 sPtani a. I certif thot�n tne formance of�he wn*k for which this OvdNFk p"� �-1'LCIt�1�J0 �Z�� �«`�V CONDiliONS �3 y p-� �,..-n����,�.. UISTRICT GROUP IYPE FIRF WROCESSED BV � permit is issued.I shnll not employ dny person in any manner �DDRE55��I3 W�N«ww+� w / �ONST LONE �p so as to bemme s��bject lo ihe Workers'Compe�satian Lows. l �� X�r �1 � P�,1 Q '{�J�l zic �{?(OS t...;,t✓ y„ CITY� STATISTICAI CLA55 ICATI��N APT. CON00. iJ p�te—. ADplitont qHCHITECI UK TF.I. f1d NOTICE TO APPLICANT: If, af�er making ihis Certifirate of �NGINEEN �"�'�"t� �CY�''e�I �0. ZLb� C�nSS NO.�� DWFI� UNiTS_ � f.xemption, you shoiild bec�me subject to the Workers' ,i L (� ]� �� Compengption provisions of fhe Lubor Cod�,}•ou must forth- qGDRFSS `�'�� �1�+���4. ��p"im4" GEWEk MAP �" with comply w�ih such provisions or this parmit sholl be rE� VALlDATION deemed.o�owed. coNrRnaoe � �S I� rvo S'ZLG1 a�. �c;. LICENSED CONiRACTORS UECLARATION p LiC I hereby offlrni�hot I oin frc.ensed under proJ�sions of Chcp�cr 9 AUUR:55 L r S NO. �e�1�-- VALUATION (corcinienciny with Sectian 7W0)of Divisiun 3 0!ihe Business and i iC- ,/� �� .P Prvfrssions Code,and my license is in full force and effeU. C�1� �1�� �r��� C1A55 �'�S3 � � 1�V ' � Q, y G SW FT- f� 510121tS I AM�IES I �HF EK L+cense Number �v���" L�c.Clnss��J� SIZE t co�o-�aor�'RL.. POOL.S o��e�'22'S 1 uescRiNTioN oF wokK NC�W � NEW � 3 ADD � � I om exemp�froin 1he Lcensing requiremerts ns I am a _ FINAL / licensed architect or a registered profes-sionol engineer A��ER ❑Y pUing in my professional mpocity (Section 7051, � �i4iE (� �•a "'� REPAIN Business ond Professions Codel. UiE O� � ,�\ � FINAL. EXISiING BLDG �Y[.J�J G� DEM:JL By � �.�� _ Lic.or Reg.Na. Date APPLICANT A��� Tf� ' .. . •. �'(;F' 1 OWNER-BUILDER DECIARATION �Nk���i� �� �►=No �s-u6 r , _ I here6y atfirm fhat I am exempt from the Contraclor's license G/ /J/} / C� � o �� �I Law ior ihe{ollowlny reason(Seclion 7031.5, Bosiness und �✓GRFSS Ci li� �V`n s%��/� pG'��E� ��� � I C �'�.- %ofessians Codr1' �'Kt�E�'� ❑ ' Rliltfllid:; i{.'., I, as owner of ihe properfy, or my employees wilh AI�I)RES� ° " ` r''-�'� ' wages as�heir sol�-:compensafion,will do the work ond tho strudure is nol iniended or offerea inr sole��ecrion �`V�`�'��'TY ��.L!"'4�� 7044,Business and Professians Code). MOVING Tt� � i,ns owner of Ihe properfy,am exclusively cenirocting CONiRnC70ft wtlh licensed contraUors to mnstruct ihe pro�ect(Ser- qr�u�SJ � r:or 7044,Business and Professions Code). Reouiaeo r�1ni sFiuncK Fuonn exist. �� ;5 2 7 A CONSTRUC710N LENDING AGENCY SfT NACK YARD HWY pROG I.INE WIOTH I herebry afFirin�hat Ihere is a mnstrucl{on lendinq oc�ency tor fupNl t�a i. a u s 1 �he pertormonte ot tho work for which this pnrm�t is issoed v i (Sec.3047.Civ.C) 910F ( n k Lj�.L.(1 PL Lender's Nnme� ,( G�� e m .��j,rj`'�: � P C fre S � •J� Perrn�l Fen � _ Lender's Address______ -- y'9 �� � I,i�L"S'G I certify that I havr, read this applicmion and stale ihnt ihe Isauonce Fee i�'�� - abave inforr rion is carrect.I ogree to mmply with oll County i„�eet�qoi�un Fre /�' �-� ordinances nd S�ate laws rel ting to building mnsrruchon, iorol�ee a�7'•��' and here a��horize rep�es tatives of ihis County to c�der �� �p ho�ie meniione perty fcr Inspection purposzs. d f��a SEE REYERSE FOR EXPlANATORY LANGUAGE _ �s iyi ��re a�Ap�licani nr Agenl Daic _ .y--a _�' �--- ��_.f.� .,, `� Y� T ` Q ..� ..-- 'l��.r� �O� , � � s �� ;� '�, � � v1 � �,� � . �Q� 'U ` O n N � � Q '� '�r'' � � 1 � O -�� t. �' � � p � � q .3�� ' n � ...f� ? 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