0109-152 (RR)I hereby affirm under penalty of perjury that lam licensed under provisions of b U I L U 114 U 7 F, t K IVI1 1;
Business anIr 1 F
DAT
_vAWAiiiirr 4*
Chapter 9 (commencing with Section 7000)'6fbivision 3i,ohhe d Ali V
Professionals Code, and my Llc6hse-. is, in fulf force and, effect.
License # Uc.Class 'Exp: Date
JOB SrTE APNI
%zip
ADDRESS
43� C39mc 11
77(YAO'
Date Signature bf COntiactor
OWNER" CONTRACTOR DESIGNER ENdINEER
i'
:f
'0 WNEECLAR' ON PdAwmkks��IMWOWNEMJJII N nURALD ROOM0. C
R -BUILDER D ATI
I hereby affirm under penalty of perjurythat, ia m'exempt fr6m the CZntractoes. P.0, BOCK I mb A;% 83-397 PEACH DT t
tAQVn�Tx 1=10
License Law for the following reason:
CA" 92201
1, as owner..,of the property, or, my employees �Viih* wages -as their S016 60)347-9869 CB1,0 508
compensation;Will I do the work, and the structure' Is not intended of offered for
sale (Sec. 7044,' Business & Professionals Code). USE OF PERMIT
Wio,,iip,owher of, the -property, am eiclusively cont acting rwlth licensed
contract6r6'-to'&nitr6ct the proj6ct.(Sec:9,7044%Buslness;&- Prof�sslonals t
Code) X,
'd - S -reason.., R&RCK)V WITH CIASS A MATIURIAtS. bf= 21
I' me t r Section r, %
Owners
-1 C1
Date i !f.7 ra 1, nf.J P 4.
4.7
WORKER'S COMPENSATION DECLARATION
* - - - _ I 'i ,
I hereby affirm; under p6h6Iy;ofiperjury-one-.ofh i11owing ect
aratiohii
J&ij I have �i4lkili maintain -a cert icate of consent to I self -insure for workers' VAUTATION 11390.00 LS j t
ompenis`afio
C .3700; of the - Labor Code, fdr,..the X.
`n,,��Iis pr6vided foi by Section ;
'1 pe ormancefof the work or which this permit'
is Issued. SEP
(,I)' I have and will maintain workers' oompdnsation', insuran&e, as required by
ion 3706 of the Labor Code, f6r,ih6 performance of the work for which this
- - .1; .1 a+' CITY OF LA
permit Wy compensation Insurance carver & policy,no. are: F
er it S'Issiu6d.1 workeirs compen.
INANC= 4t ori
Canter
Policy No:!
KIND
DL
STATi XMMATED C0Vr OF COMiMUCTION I ISM -00
�T,-,(Thls section'iieedinot 64 c�mol6t(Wffihi"' PERM FM 911JAM"M
6 pirmit valldafi6h is f6i $100.00or less).
('certify that In the performance of Work for which this permit, is issued, REROOF FEY,
101-000-418-000
shall not tion laws'ofCa
employ any person in any, m'anhbir', so as to become subject to the
_�ibrkers' compensation llforinii° and agree that'if I'should b6come
-
subject to the workers'.6hripirisatioin provisions of Section ction 37 of the Labor
Code,
_sh !11 fqrihwith comply with those /",vision
A
Date:' I z/ Apolicar t
��W'arnlng.-:Fallure to secure Workers' 6;mp6*nQtlon coverage Is unlawful and
Jshall subject an'emplo'yer.to'criminal penalties and civil fines up to -$100,000, In
UdditioA to the cost of compensation` damages -as provlded'f6r in Section 3706
Nof the Lib6rC6d6,,;,Inteieit,a6dittomey§fees .,:tp,
fimlibwAkf 'ApRcation Is her*eby'made to the Director 6f Building and Safety
iVor,a,per I mit'-,SUbjecGt6'1't6e conditions ',ihd,restrictions �set forth'�:On, his
'T- '. . to
7 . I J#
. , i,! t -,T_ - -
appllcptlon.,.� 4 x
_ r,' j� l,l 17
Mai
.. - person at
Each person this application Is made & each
`J� .' iierf
1_1 whose request and for whose benefit work is, ormed under or pursuant to
SUB-7MAL CONUMMMON AND PLAN CIN= 1 $30,00
any pe . rmit iiideid aillresult 'bf this applicaton agrees to,.& shall,. Indemnify
UMS, PRE-PAMD F=_ SQ00
"A 'hold; harmiIiis',f1he"Chly of La',.auiiiita, its office agents and e pl6yees.
t `officers, agen
In
t'o this: Oppl�lcatlon becomes null and vold.if
�.2.'An�`peii�lt lis666'asii a resul"", I,
work ls'nof'omin6hc66iwithin",160�dayi:fromfdite.'of issuance of such
TMAL PXR=r FM DUE NOW
�permit;'or cessation of work f6t'.'.1*60'jAysI�wIIl Subject perm' 106 'Cancellation.
I.
have'rea this application n'Is.' 6kity t6i'f d i0licatibn and'state that the above InformatI6
�c State la� vi relatirig to the building
construction,"taAd herBby.iuifio zeIre presentative's ofthis City to enter upon
the above '-mentioned 'oropertyf6ir Inspec1lon- purpose
RECEIPT DATE BY DATE FINALED INSPECTOR
SIgnature-,(Owne*r,iAnAn't); Date
A;-, A
V
2—L