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
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