HomeMy WebLinkAbout08_13_1985 - 21015 PATHFINDER RD � � - � . Q -
-OMPENSATION DECLARATION� � .�. . . . . . � - - -- � .11
°� °e°���;,f;�°�e°f�°°°e°�,°°Q�F APPLICATION FOR BUILDING PERMIT �s
C •ker4 Compenslion Insuronce,or .
�'�°��p . ..3600,�v !C.) .., - COUNTY OF LOS ANGELES _ BUILDING AND SAFETY
�y��u'j�O�s .:omqany _ . .
`by`f3� / .iereb furnished. � - - � BURD�NG .
„ o� 5s v t CO. FOR APPLICANT TO FILL IN ADDRE55 Z i� t 5 �a-����=Q�e-p
0 9r.�6 .s(iled wilh ihe toubty building inspec• BUIIDING ,�/y� J!'7i7'�F����Y��'�_ _ � ..
a`�'n��s :M. . � _� . ' ADDRE55 [/� f"� �ocnurv��'R-tiho�3'C�'�:�� �
6��� - . . ' . � -.,,,,,, +^ NEAREST � (�� .
%'ScsR —APPlicont . . � ... ❑TY f.a/�,YwM—� . . CRO55 ST. C rJ'-'f'O� �V ,
o NO.OF BL�GS. 1 ASSESSOR- ,
^�ns ATE OF EXEMPTION FROM WORKERS' ' � � ,
6 COMPENSATION INSURANCE � - ' ���. - SIZE OF IOT. ._ . NOW ON LOT U EPZ OOK ��P f' PAGE PARCEL
y -��need nor be com leled if Ihe ermif iz for one �l ?
cl� � ollors(S1D0)or less.) � �P .. TRACT I'iS�L BLO�K �' LOT ^�� NO. ' J . �, .
� '1��--�v �-7 TEl L•!' . SPECIAL p / p.
Ihat in ihe erformance of Ihe�work for.whith ihis �WNER� � /N.Gti�.LJ- NO 7 � - CONOI110N5 C� �g 7 V � , 0
i P - ��� - � � �ISiRIQ� GjjOUP TYPE FIRE PROF ESSED BY. V
— -i is issued,I shall not employ ony person in ony manner ADDRE55� Z� /�/�kEZ.L �'C%�T�I�a , of �' Q� CONST. _ ZO E /'� � O� —
�s to become subjeu to the Workers'Compansation laws.- . rr� /) �--rt— / I
arr�T�cl��uE nc �Z /� ._r._ l/' �- _.
.ate'�� Applicont � -� ARCHITECT OR A _TE�. �4 STA715�ICAl ClASSIfICAiION APT. NDO.' V
.- �NOTICE TO APPIICANT:�If,'afler making this Certi(ico�e of � ENGwEER /-F ! -No. G- --3/ MSS NO.� W
DWELL UNITS � � y
Ezemption, you should become subject tb Ihe Workeri �/
Compensalion provistons of the Lahor Code,you must forih-� � qD�P.E55� �IO C�f�--��--'v��� ���1�7�'��7c3� SPl:ER MAP - z
with comply with such p�ovisions or this permit shall be � TE� ' � ' .
deemed revoked. � � . � CONtRACiOR NO. �j�" K. PG, VAU�ATION
� IICENSED CONTRACTORS DECLARATION ' � -7 G �A/ LiC. � �� � -
- I hereby oifirm thaf I om licensed under provisions of Chapler 9 ADDRESS I I L(�YY!IT��1L. NO. VAWATION ' . � � - '
mmmencin with Section 7000 oi Division 3 of Ihe Bosiness ond �•/�'f �"'' IIC. jj �
Professians Code,ond my license is in full iorce ond effect. CITV-i�/�v,�y QASS'�+�� ��f��j��• � " . .j'i� �
� '��( �� S�.Fi. NO.OF- NO.OF CHECK � �
�li[enseNumber�'���� �lic.Clats� SIZE r� STORIES Z FAMIUES -�-- ONE �, . �; ., e o J'?, � ,
R�1r..�w,f//�: T�,a,v:-�r1�vc� N� ❑ E � i, � � �,
Confrocfor�7��/�/tiw�Date f�Il3�'S , DESCRIPTIONOFWORK �� � - - _ � , �
a ❑
� I am e.empt from the licensing requiremenis os I am a f�t� ,- _ , ti� ���� ADD. _
licensed architetl or a regia�ered professionol engineer_ ,,_ _ .. ,. . .. ALTER � ,DA EL �v/2S/�� �
. ocfing in my professional copacity (Secllon 7051, � _ � !C-i7/�� REPAIR,� ' 1
� Business and Professions Code). . � - USE OF � ' ' " ' � ' FINAL � - � � - ��� ,
. E%ISTING BL�G. � ti�J� DEMOL ❑ B . --
LiC ar ROg.No. .. '... . .. Date APPLICANT ' TEL. f Y . . - . . .
� ��'-' - OWNER•BUIIDERDECIARATION � � � - � (PRiNT� Fii-»c :L�� NO. _ � . - .
I hereby affirm thot I am eaempt from the CoNracror's License qD�RESS I_I �2 1�'L l'r��lGlt.. _ 31� - �DmR. �yD7- - - � .
_ law for ihe following�eason(Sedion 7031.5, Business ond . - rp C . .� � .
..Pr❑oies:IonsCode):.. , . .'. . . .... . . .: . PaeSEM r� . . �/�� .5��,�: ' _ .
BUil�inlG Z �•— t�i�`�-�'F ��i:�
. n
I, as owner of the prpperly, or my emplOyeeS wilh ADDRE55 ' �n��� C��ryl�?���y/
.wogesastheirsoletompenso�ion,willdotheworkand - ��A��TY--1���,M.b�•�7 - �LD�� . . .. �Yi �1` �-- ,
-�- --�Ihe strutlure is nol Intended or oiFered for so�e(Settion' ' � , . , .. . �
7044;Business ond Professions Code). , MOVING - - , .
- �_�I;as owner of the property,�am exciusively conlracting � CONTRnC70R. N�� � � �', � � ' $�'?S
with licensed contractors ta canstrutt the project(Seo- ADDaESS � � � -� � � � � -
..� tion 7044,Business and Professions Code�.�. . �-- � � , � - �
REOUIRED TOTAL$ETBACK fROM E%IST.
� �CONSTRUCTIDN LENDING AGENCY SET BACK YARD HWY .PROP.LINE �"/IDTH . _ ' . " i "
--I hereby affirm thot there is a conshutlion lending agency for •-- FROM . � � � � � . �
the performance of the wo�k for whith this permit is issoed �� P.L . � " � ' _ � �
. (Set.3097.CiV.C.). ... n . . SIDE . . . . . - . . . .. .
� ♦ I f • � P.t. � " . � - .. ,
Lender's Name � .. �Q S � - �
� P.G.Fee S ,� Permit Fee }� � . ,
Lender's Address ,. . - - �I� � � � � � � � � - � - " ,
I certify thot I have'read this opplimtton and stoie thot the L, b � - � � � -
Issuonce Fee
bove informaiian iz coirect.I ogree b mmply with all County. . in�esi�garon Fea .- -- . 1-r�p � . - � ' � � � � ,
r i nCes an Stat aws r ��9�o building con5lroctiOn, To1ol Fee t/ � '
ereb au horiz presenla e f ihis Caonty to enter : - . - .-- -� ���- - �
�he a o i �oc d p r inspetiion purposes.� -_ , . � . -��
SEE REVERSE FOR EXPLANATORY IANGUAGE
Signowre ol Appumn or Agent Ire . � � , . � ,. � �� •
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