HomeMy Public PortalAbout10870 FREER ST_Building__ W
KERS'COMPI:NSAT64 bEb kkATION r j —
}_ '
rnt that'�.hay. a terttfl�ah of consent to Mff y � IJ0
I D I PERMIT
eriiy t h of WorRbrs' Cbmpernotipn InwFanc., `t
NG
copy thereof (Sec, 39M, Ldb:C:) _ � `•C�Ut P 1,
Company BUILDING AND SAFITY
s Company.
BUILDING
lid copy Is her*byfurnfahed.• -XP.PLICA�Ii TO FILL 1Nr .'= ADDRESS
di rifflid copy Is filed with the cbuhty building Inspec- fw
WtV 2W ID 9,01
TO
LJ tlon'deportment.
I
DdteAppl lccw" CfTY A
P 1 rVLfry
CERTIFICATE OFLXIEMPTION FROM WOMRS" 140.CFAGDO&
EN
COMPSAf I ON I NSU IxANCE BIZE OM LOT X ST.
(Thlt s�ctlort need not be com lend If the permit Is for one ( O rZ O i0T nib.- -ZMAPEI(Xpie PARCB
hundred dollars.(S100)or.less b
1 Ji ortt£y fthal In the•perfprmance of the work for'whlch this,. TEL
MMMr NO,
permit Is Issued,l shall not employ arty Person In arty mariner 5
W.de to become' iblect to the Workers Ggmpensatlon taws:
lTfiG�'- ZIP _ ._
Date 7 AApplicant ARO-IFECT TE1 2.l DISTR}Cf P TYPE A t3Y
tr
NOTICE TO i If• after r�akirlq thfs Certt4lwie of NO.
Exemption, you•should become subject7to the Workers', CC T'
Compeneatlon provisions of the Labor Code, you must forth- ADDRESS
with compl'y. with s4ch .provisions or this-permit shall be _
deemed revoke&, - STATISTICAL CLASSIF T1CKJ APT. [n
LFCEI`SED CONTRACTORS DECLARAMN LIC. CLASS NO. DWELL UNITS_
I hereby affirm that l am Iice'nsed under provWonn-of Ux"9 ADDRESS too.
n»ricl with,Section 7000 of Dlvbloh 3 of+,@DLWrmiw'and - LIC
�rofewlons Code,.bre rriy Ileerrse 1s In fall force and eff�cl. CRY CLASS VALK)ATION`
SQ FT P4 NO.OF No.aF _ a�ac
License NtJm Lice Cldas SIZE SPORES �^ LES OPE 1 [L •(� pi
Contractor bof�. �,r.
DESCRIPTION OF -_ NEW. ; T� . #
pI ani exempt uG nder Se2 S11�.. ' 1�� ADp , I :.'t�0
-8-&P.C_ for this riason _ - Ovy, kew
Dat. �TIIN&UDG. N ` DEMdI !! CVJ , o o 2.3
SiqTKture APPLICANT TEL I - n
OWNER-$ul DECLARATION PRINT 4 �' OlJbJ DATI
I hereby affirm that I pm exempt from.the Contr ictar'sticense
Law for the following't+cssdh (S+ctlon 7031.3, 6uslress and ADDREM R Zat7 c
PtoF Ions Code): au INCL 5-73-3 bya t " •�
I, as owner of the property, or shy employees with ,ADDRESS i • t 1 �I C 117
wages as their sole cgmpenwtlQn,wlll do the work and, `�..}� \� � r
e structure Is not Intended or offered for sale(Section
the - ��.�
7044,'Rusiness cod-Prikfesslons Code}. MOPING TEL 1,'4. •.r:
I, as owner of the property, am exclusively contracllnq �'. � M
with llcerised`contr om to'construct the project (Sec- ADDRESS
-Hon 7044, Susiness and Professions Code) ' �•;.\ 1 4
COtJSTRucTiot4 LENDING AGEN-ty YARD HYN D
I hereby affirm that then Is a construction Tending agency for27 P>0
the performhnce bf the work for which this permit Is issued `,\13&9 i
{Sec, 3097,flv. C.). SIDE
P.L.
LshdWs Nam i LDMA Ref.
8 a Perm R FM �.
Lshders Address
I certify that L have read this application and slate that thePOO!".
� harmce JC) � � CDMA P/C!-'
o above Information fs correct.I agree to comply with all County In,"tp tion Fee
brdlnances and State.laws•rslating to building construction, Total ' Perm.
- and hereby authgrize nepresentarivss'of this County to enter
upon JFL&above-mentioned property for arapectlon purposes
-
c SO lRVIJIt PM DM AMATORY LANOUAGI
Sl�of Apo icm. .6r AV•rH DW - - .