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HomeMy WebLinkAbout04_17_1985 - 21073 PATHFINDER RD ..... ..: ...... ... . i -- . __- ---_ -- - - . _____._.. .___._..__. ..._. -- .... .... - - - - ---...-- ---.._... , .,.,. . . _-__ __ _ .. . _. _ ._. ._ ... ._ WORKERS'COMPENSATION DECLARATION ; .:'.' '��"' ' ::1� � -"• ' � ' � _ • � „�, . , . . , �. ,� - . _ .._.... - _ - � . . I-hereb afiirm rha�I have.a cenificate of�o�,e��,o,e�f ��/ APPLICATION �FOR �,BUILDIN�G PERMIT� �� or a ce�tified co Iheref Workers'Compensation Insuran�, // . Y �nsure,or a�certificafe PY of'(Sec:3800,Lab.C.) „ .",, ' f�� --'- -�- (';WL `• , ' . • '. •'� • 1 � COUNTY OF LOS ANGELES BUILDING AND SAFETY � •�i PolicyNo:������ Compony ��N� � BUILDING �� �-w� � ���� I����� � ' �� �b'' � ified copy is hereby furnished: • �� ;�. FOR APPLICANT TO FILL IN ADDRESS ����7 7/��//I�O�� �� � ' Cerlified'copy�is filed�wilh Ihe w nty ild ng�'nspet- '"" BUILDiNG �+�//� �y /� � // '��tian'depa(rf�m` eM � '� � � :' ' •. . ` ADDRE55 4�IV7J ������.r�[ ' . Dale 7�'7GS Appliconl ,� _ 4�1� _ ^Zlv '- ' LOCALIN �I' IG�.» ' CERTIFICATE OF EXEMPTION F O WORKERS' �t -NO.OF BLDGS.- - NEAREST_._ . •.� � --. _ ... . . -- ---- - � - �� � • � �COMPENSATION INS R NCE . . SrzE OF LO7 NOW ON LOT d�G' Ca055 ST. �C�i�:V�f, ,cDo �}i L7/A��D�-+� .... ,. ....... [Thid seUion need not be�compie�� ' 1he'permit is for'one - - - - - - �/ f�-- ' '��' ��-�'�� � ' � � ----. TRACT I ry`�I G.. BIOCK � �'--"�'-� LOT NO. L MqP BOOIC i.�`• ,.. PAGE� PARCEL . ' Y ..... P ., : . . -�+ TEL. . . ( I ) 5. •.�. .,.,... . ._� OWNER�/�I�TN�IIUOG�:Fl.[...."'_NO. � =�J[`f)!__ USE ZONE �P y� > hun re o ors 1 or ess. I,[erhf that in�ihe erformance of the work for which this � . `'�`�� ' " �'�} peimil is issued,I 5hall not employ any person in any manner _, -- - - SPECIAL-.-� // �� a - ADDRE55 I �Z������C'ZG N`i SP� G-��U �ONDITIONS G IJP�6 7"� Q so os to become'subjecl to thc Workers Compensarion Laws. �- �� V .� ,.,...._. . .. - . ,... •. � • ' - ' -- "' ' - � � � , .. , . . .._.. CITYJ 4�.V/iV�-- _ __'. __ ._ZIP f/cn.7�� , . _. -_'.___. _ ..._. .. . �0[ �ate � ..'.,,��'.�•: rAPPLmnt �'' ' . - - ARCHITEQ OR TEL. .O NOTICE TO'APPLICANP. If aker�mak�ng'Ihis C�rtifimle of ,4Gsa�S.vAP NO. ' - QK�) .DISTRIQ._ ,GNOUP TYPE. FIRE _ PROC EDBY_ . F Ezemp�ion,�'you;�should become•subjecYto'tha'Workers' � � ENGINEER CON,SI7.,�/ ZON � W CampenxnNon p.ovisfons of rhw lobor Code,�you mus�forth- qpD2E55 �rn.�...'-P��/ti» ttL�� j:1!'G' �I�$ ' • �._ ._�� (//L-.. . - �N with tomply witk soch provisions or �his�permit sholl be � -- ~iel Sia715TICAl MS S gi��ON , � APT. CONDO.' Z deemedrevoked:lc+,.�.,�:" .. .�.•. . . ..�• � . � COrvtRACTOR�����c�J �'!Ai�T%� NO. � aD' �L�D ' '.- --_'. _ . .. . I . ..' ' ._.".... ..._..� . . LICENSED CONTRACTORS DECLARATION. � '�� - � -�� ��� e.y �-- � ii�. �- i QA55 NO. � � DWELL.UNiTS I hereby offirm 1ho1 I om licensed under provisions of Chopler 9 . ADDRESS /(t / �'�j'7�TL' �ZL NO.��7��s' .,..- . A .'-.IIC.--�- SEWERMAP . . � ^9 , .Y ) .._. - ._(f�7� � , , `. , :: f ond :.._--- CItY.�'�✓/A�L� �1 C1A55 �-� . .•-•--�- � - - -� �----- VALIDATION'.. . commenci with Sedion 7000 of Division 3 of the Bosiness _ _ Rofessions CoHe,and m license is in full force and effet � 8���-��-�7�j� Cont�a[tor � Date � �T., NO.OF NO.OF CHECK ' ' � f7�15�� • • n . ...- -- - � `" ' � ' ��� z +��� �' SIZE� OCO $TORIE$` FAMILIES ONE �- �� � � , i � � � . . � __ � LitenseN er / lic.Clas • � �y-��� M ' VALU/A�TI - ' ----- ---- � -- � .. -- DESCRIPfIONOFWORK !G•vA��"-l�t�/�111 N�'""O , / ��/ �O . '. ��a� ,h•• . .__ _ ADD � ' _✓ O�G'`� f � . . . Y ' �I am exempl onder Sea � -- '-- -'-----�-�-�- . '�� �n.���i�h � . . .. . ,.. . -- - -- "❑ ' "f . ... ,� ;_ �, � ALTER . .__ _-___- � ' B.BP.C.for�h� CO50 _._. REPAIR_� s.._�_ . .. ........ "" ' '_ i _a ' ,_ -- .___.".__.'..... .._. . . .Date:........... ...: � � /�� � . .' . '_ � i.. .�,... E%ST�INGBIDG. ��SI'f�L�L �EM ❑ �' (f� ' . ' ,_..,. .�.. ._ � , -_'.-Signa(ure -.. �." - ' � APMICANT-r���. .` J '�-'' TEI. .. � '.�..., � ��f`,rl.J s , DRINT T/-K-/F/G/Y�f�'.nT No. -tnc:7 FINAL O R-BUILDER DECLARATION , ___.___ _ ;.DATE- � � � ---'-� �- - - - --- - _ . .- - -V---- - - - - - 17..& . •.... . . ..I hereby affirm a 1 am ezempt from Iha Contmctor's litense ADDRESS J O�� �T'�/7L�f�G�' -I-.��!!�G e '�i,O:�.:�T;n . law for the fo o ing ieason(Setfion 7031.5,Business and FINAL�- � "� � ' g- ---.- .'- .�.�-j.-��-%f--,4�:.. .' 'Profess(onsCo :��-�'�" � �� "- ""� �--'"- �-"'� '-�' aRe NT . Y O '-' BUILDING . . . . . I,as owner of the property, or my employees wi�h ADDRE55 - ' . ' ' ' - '. ._ _.. . . _ . . .. .. - - - -- ---- _ -.. - wages os iheir sole tompensotion,will do Ihe work�ond . � � ' _ , . Ihe slructure is nol intended or offered for sale(Seclion ����Tr . ' _ -'^�F� "' --•—-7044,-Bvsiness and Professlons Code).- -.. -_-. .--- MOViNG- - �----'-- � � - - ---��-�iEL� - --� -; .._. . .. �.. . - . . '- -- �-, -, � I,as owner of the property,am exclusively controcfing �ONTRACTOR NO. � : " '2`� , - � wi�h Iicensed conMactors to mnstrucf the projett(Sec- " ---.._... . .... . . . .. .'-� --.... ....... ' ' '.. --�-- - -.... . ... � . � � ?�.'1�. tion 7044,Business and Pmfessions Coda). ' ADDRESS I , , , .. ^ � .._____ __ __... .REOUIRED.._ TOiAI SEiBAIX FROM- XISi.. ' ' ��. � -. s -;n �•_,` VARD HWY- • •�.._..�O ' -�-�CONSTRUCTION IENDING AGENCY" '----- SET BnCK PROP.LWE WI�TH� � ' i �ii 7 �-���� ��, 1 hereby affirm�hat there is o consiroUlon lending agenty for FpONi , � �� -�;,';'r��n r � � -Ihe per/ormante of Ihe work for which ihis permil is�issued -'-' ' �P.L ._._ ._ .'__ ._. ._. ._'. ' ..' "....._ .. f _- - . '. '.. -.-_-_..-,_�-e•'.�.�...,�- -. ($ec 3097,Civ.C.�. SIDE , � . _ ' . ""'. ... _-.. _.__ ._ ._ . .... . ._.. _____ _... . 7.L. .. ._ _- __.. ._____- __._.._ _. _. _ .._._' . .._.. ..._, ' i 'y�-; : ..lender's Name !�� � � . . --(i�t�,� - . . Lf/✓- �IDMA Ref.N .. .. . ` •• . .._ ._.._' _'.. .. _. . .. _..___'_ ___ . .._ '.__._.. P.C.FeeS_.. -/.iv ..r--_- PermirFee". _.' _ ' .. . ! . tender's Address p. (�C �f Q .� � � .I.certify.thot I hava read this oppltmtion and stota thal the . -��p��� Issuanca Fea�- Z/J�-- IDMA P/C#O(O �-- '- -- - --� -� � �-� .. .__ . . _ above informatio is coned.I agree to comply wilh all Co�nty Investigation Fee � ' � � ordina es and 1 te laws relating fo boiiding tonstruttion. ._ _.. ..... _... " "'.......__" . Tofal Fee- � --' ?IDMA Perm.M�g � - �- - ��----- - - • . . I and h by ut ori e epresentatives of this County to enter � upon Ih a m nti ned properly for inspeUi n p pose. � i . _ __ _ '__ _ _. _. ., _ .. . . .__.._"._' .... . _ _'. _"'. "'_ _ . ... ....__'.'__. .__." " _ . . _'_ . . . _ . . .. . . I, � � SEE REVERSE FOR EXPUNATORY IANGUAGE , 4 , __'.� Si namreofApplimntorAgenl'.._.__. ._ _ _. t _ _" ' _'_ ..._____ _._. . _.'.. . .{ .._ _. '_ _ _ _ '_.'___. . _"' ____ �n1 ......._. _. _... ._._._... ' I i --_---�._.____...._��..�__._�---_._._.__�-_.._�..... .. . - - . - --- __.,.- - - -- - ' . .. , ' . . . . . . ' ` . . '. • , • . . 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