HomeMy Public PortalAbout9552BISBY ST_Building (5) WbRK�RS'COMPENSATION DECLARATION L
hereby off lrrrL that l have,a certtflcafa of consent to,b}f P Ll ►Tl O 1� FOR"BU�L D I NPERMIT
In}ur�Nor-acer`�flcate of Workers' Compgnsatlon Insurance,or a certtfled copy Aerebf (Sec.3800, Lab. C. 1 COUNTY OF LOS ANGLES BUILDING AND SAFETY
PoliyNo. Company I-red-r .t^' ^'t�.
Certtfled copy f hereliy.rfurnlahed. - APPLICANT O FUJN BUIIDwG
ADDRSS1 57,5
[�
It
eopy is filed with the court bulldl Insppecf BUIIDINC '
.Itort depart4m�nt.
Date• IO pllWnt C1TY , e- l.1 ZIP l / LOC LFry
CE1016 FROM WORKERS' ,OF BLDGS.
RAt
COMP$JSATION I SIZE OF LOT NOW LOT
NSLI
(This settlors need not be.cp.mploted if the permit is-for one - -
hundraO dollars 0000}or leas.) TRACT FLOCK LOT NO' MAP' PAGE:. PARCEL
LIS�ZONE
1 c`erftN fhat In the per4ohnancb of.thi work for whlth this r r Nd. J 5 *�-
permlt Is Issued,,I&hall trot employ Qny pir4bn In any'monner SPEC]A1
so as to become su.bied to the Worker %mpen IQn'Lawr. s ODiDi110N5
11-1 j. ZIP 17
Dote App lIcaht ARCHITECT oR 1a
NOTla TO APPLICANT: If, aftir•mdklitq'•thla-Cer"cate of NOuablff� . DISTRICT. GROl1R TYPE FRE BY
Exemption, you'.should .become wbjrct.td. the Workbrs' COIET. ZOtw
Compensotlon provWorwof•the Labor CoA, you mint forth- ADDRE§S
with .comply wlth..such provisions or this. permit shall be
deemrd revok}d.. •. OONTRALTOR f SGg �✓ STATTSnGl. tOONMDO..TTON f!1
UC�NSM.CONTRACTORS DECLARATION CLAM NQ.�-4WEi_L UNItS Z
I he _cr.flgri that I am licensed:under pCh
rovWons of apter 9 ADDRESS 0217 SAAao FM
(oommendnd with Sedign'7000)of Dlvbion 3 of the Busyness and ' SEWER MAP $
Professions Code;.and my homnse ]*.in full force and eff&o. CITY C1ASS. (— ' ..vAAA1 W V.
SQ. FT. NO.OF NO.OF PG.
�I�e�usi Nurti LIC C SIZE STORES FAMILIES � � e' t
Y DEscAiPTTON of WORK VALETA ( a o 22 2 5
"� �' NEW DD ° °•2:6 2 5 6
AM
I am exempf".4nder Sec , ti' ALTER D$ 1•9'—88
B.BP'.C.for this reason E2 �}V RP?Nk _-:.
Date: 113FOF
D(ISTTNG BLDG. DEMOL
APIIVCANT TB...
54gnature OWYNE�t$UILDER DECLARATION I NO. DAT�:.S Z�..� 0 4 a 9
I hereby affirm'that I am exempt from tb*.Contrado lillcense q >5 34 151
Law for the followlrtg reason•ISecflon 7MI.5, BuslrN84-and ADDRESS A
Profesarons Code):, ° 3 9 8 8 3
❑ '.1, as own& of the property, or my employe" with 0 E,1 9 8 8.
wages at tfiefr'sole cgfipensatlori,will do the warn oho `
the tfructure:lt not Intended or offered for+ale(Section G
7044,-Buslness and Prof"Idns Code). MQVINCi. TEL QQNTRACTOR - G
1, air own*r of the prgperiy, am extluslvely coattacting .
NO.
—+-wMh'Iicinsed'con"ctors to rbmstruct the proleaf'(Sec- ADDRESS �
tlon7044, Buslneas and Professions Code).
FROM
CONSVLK- ION TENDING AGENCY YARD. FWY AL T11. UNE DTH
1.hereby afflrrn that then Is a conWuctlon londing agency for FROtff
the performance of the-.work fof which this-permit is issued 'P.L
(Sec 3047, Ov: C.)• SIDE
P.L
Lender's Name
`` '77 LDMA Ref. i
8 Lvnderl Addres P.0 Fee$ (O'0? PermR Fee
L certify that r have read this application and state thot•the' . - isuar5 a Fen P/C f
above' nformKrHon Iscrorrect. I agree to comply whit all County Inwsrtparbn Fee
ardInances S laws'rek ng to building constr•u�ctbn, Total I. EDAM Perm. # -
and ntotives of th( County to enter
f
rhi forInspeclon purposes
-I8• >sa ffK)R 101ANATORY LARGO^ a
Applhar»or Agent Dat. - _