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HomeMy WebLinkAbout0587A 0588A (4) .: . ,_ ._.,_�-_ �- _ . .. AP�'l.ICATI _. � i WbRKERS'COMPENSATION DECLARAI"ION ��� � - � . �.- , � � - ��� , .. . _ , ,.... , "o-m tha),I,hove a certlfiwts of consenflo yelf . ' Ol�I FOR��.BUItDING� PERMIT���� � �� � �� 1 f�Workari Compenaation Mauiance, f �Ifi theroof�See.3800�Lab.G) .. . .....� �. ...._. ... . . . . � � . .,. . . 1" !� � ' COUNTY OP LOS ANGELES BUILDING AND SAfETY j'� ..y.do. Z Compony � f'Rl�d�( � � � � � � ' r ,,,�1 i Cenifisd co i�hsre6 furnished. BUILDING� /�1 1 I�� � j L,.t � pY . � � � FOR APPLICANT TO Flll IN AppRESS � g� � CenlHed co a ft�ed w��h the eoun bu id�n ms ee- L:-t't Date�i j PY� b 4� P BUHDINC . �1 . - � . il de rtmenl '� . �'. - ° . ADDRE55 Z l.r�1 A�'Vp L. � � � � . �,,�y'� . , Y�" .�. . .. �. , ... _ ` :. � ��II�Applican� (1/'�'�"L ('— CITY � ZIP� tOCAtI7Y r'�"' �.. a . .. . . . . . .. 1 � corna�sanoN iNsuaarue , . , 'I ERTI�lCATE OF EXEMPTION FROM WORKERS . . SiZE OF LOT �� rlOw ON Lo`' � �� caosss5i��S�r� a/�o�� �o(Dd.1 .fP�2:r�✓6s� � (Th1��ecrion need no�be�compbtad if the�perm�r is for one -..... � ..�-. . �.. ..... ,� _ ._. .. , n55E550R '.... .. . .. � . hundred,dO�lan(ft00)w,lesa.)���. .� � TRACT�� �BLOCK � tAT NO. ryy�p gppK�;�� � P GE PARCEL ` � '., . . _. OWNER q, � ��TEt. USE ZONF�... . . ... . .. .. ' I certi{y tfiat in ths eri'ormonPce�f 1�P;work fq�hlch ihA� � � A��� � �� e� NO.�-- � - � � . . P r � �ats - r not em lo an er;on In on mannar - �. SaEGAL.� . _ io bacome sob ecl ro ths Workere Compensanon Laws. �:� L^' cONDiTiONS - � i .4 ,.. . .� . � � . CIiT ZIP '^ . . ., .. .. .. , . . . .. �. _�R . NOTI�'STO APpkIfAM'Pplleant .. . .... �t I CE- : If;�ofler making��thi�CerfifieaM of ARCHITEGi OR � - TE�• DISTRICT GROUP T'cE � FiRE P D 8Y ENGINEER �• � � NST� ZON€ ��� i �empr�on,���you��hould becomr�sub�eu�to����the���Workera'.',� . . . , . '� � �{ I pensation�provlsloru oP th�Labpr Cods,yoV mus�fonh- � qDDRE55 � � ' ' wllh tomply with aueh�provlaiont a.thit permit,sholl he ..,__ . .. .. . � .. . �.. ' deembd revoked:- �� � ��� , - cONiRnCTOR y.y� � �� ��' . � �79 �; STAl'ISTICA4 C1A551F1UT10N AP7. CONDO. . fq i i LICENSEDCONTRACTORSDECLARATION .�� .�.� �. . . .:. .._ � ..tiC. 11� CtA55�NO.... �' DWELL,UNITS�� � " ".. . Z ofesfiont od ho�1 am licensad unde�provisiom of GhoPta V AODRE53 . � � �- �.�.. .T �R MAP � � ( � q th�Sxtion7000}of DWielon 3 of ths Buslnesr ond ...... - .. . ;_. . . ... .. t� _ ' � .. - ..:. . - � �Commen�C W�,and my Ilc�n;s b In fui}�ce and effxt. ` . Citt �.Uv � CU53 `. � �� � . BK.... �. . . . ..�YALIDATION� ` ' - 3q����.f �_ �, SO FT NO NO OF CHEqI tksne1Number lic.tla�e�,�, S¢E' ��' - STORIES� FAMILIES� �`ONE � , � �: . . Controct . �..�L Lff� �\.N-�K-"rDau �A! p7 .. �.. DESCRIVTION OV YVORK �� �l.L -.-..�NEW�... � _,VALUATION ..,.. �. � . . � , ��1 am sx�mpt undw Sea. ,.... . . � � pDD [� :�� O ' , . . .. . � ALTER � � . . . . .. B.dP.C.fw fhl�reoaon � � _. _ , . . REPAIR ..� .. .. , � .. . . _. . . .. . .. .. Da}!: .' .�. USE W OEMOI, ❑ t . , � � EXISTIN6 BL00, . . . � �- �OfU��. .�. .�_.. .. ._ . ::_ ._.__... ._... APPIIGNT ^�, NO. UO FINA� /� '7(� ._ _. $DJr H I A ..�. � OWNER-BUILDERDECIARATION PRINT r�1D �-K-�-�-� � DAT�. yr' �• Low fo' �trm lhot 1 am�x�mpl hom fha Conttaefory Utenu ... ..-. ./� ...'. .. �. . . .•� • . 51 r th�kllowlnq rsanon(Secflan 70.91.5,BuNna�ond Aoeae3s 27 �lP+� .j ln�RLa� RINAL # 23 Profea�lon�Cod�): . By ( . r 2�,Q 0 � euaoirx� , . I; cs ownm of th�property, w my omployee�wlfh ADDRE55 wope�at thsir tol�compenaatlon,wlli do thf work and � � '" � '����� �� � � � �� ' �� .._�� � ;,� � '••2 S��F� -. � fh��trucmrs I�not Infended or offared for sals(Seetloa �� ����� � � ' ,. � . : . . 7044,Budneu and Profauloei Cod�). ...... .._ MOVWO .. . ... . TEt. .._.. .... � ,.�.. ... :. .'.� 0 g,n Jr—$$ .. � 1�ot ownx of ths property,om e■duaively coMractlnq NTRAttOR NO. � � . � .. with Ilcensed eomrocton�o�conahuct fhs pro�ett(Seu . .. � ..�.- . . ..- ....�. .. . .... - . . ..-. ._ .. ... . . . � flon 70M,Buaineaf ond Profesalon�Code). � . AD�RE53 . � .. ' .." i..�...CONSTRUC7ION LENDINf3 AGENCY . . '. ' . ��gA�K��� YARD HWM'.--TOTAPSROp,II�,E .. fo7H� .�� ��. .. .. � ' � �O S$8 A � . I herebp affirm�hat�he.e��a consrr�ctlon lendinq aqency kr . Fgp� � �. . , . , �� -the performrnctr o/��he work for which�ihis pe�mit ta-iasued -... ..P.L .-- .�. ., � '' �� I (Set,3Q97,Civ.C.��. � � SI�E _. _.. . .. . . .. . . - .� #��s ��'��� , '�. iender'fi Noms ,_ _ _ v,t. + • �3 6 7 5 � . . . _ ,. � � Rr LDMA RaE M� � , - � :z Lender'q Addresa � . � . ... �.. v.G Fee i �d..3 �... p«mi�Fas-.._ . . . � � ■..�3 b�7 5� ! � fl8,D5-88 g � 1 ceriify�,fhat�hava read Ihia upplicallon and state.rhor th� .... _ . . _ . �. ixuanc.Fe.... Q. .LDMAPiC N . � d above Informotion ii corrxl.I agree�o comply with all County � InvuNpauon Fe� . � � � � � �� '� ord�rwnces nnd SI ts laws ralating to bui�ding consnuction, � � ., �� - d and here6y au r xa�repro:eiitatfves of th�a Coun�to enter �� -�� �` - Tmol.Fes.� . 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