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HomeMy WebLinkAbout10_25_1984 - 21073 PATHFINDER RD (2) ,. ;_.. � .._.....__..__._r_.;;.;�_ . ._: lr� .-/��`� �"%xti . . . . . _ _ .. --...,,, ,�.sP„ e - ..__....,.��e o*workers'Compensotion Insurance, �` � '� /'1 Z`� _ . PPLICATIQN FOR. UILDfNG PE �M��T _._ _. . y or a csrriFled'�bpy.thereo( Sec:3800 ab.C.) °" COUNTY OF LOS ANGElES. � BUILDING AND SAFETY � J �.. Cenil7ed capy is h��'fumished. ' . . �, ��. . . . . . . � --'. __._._ Policv o pany �� � - -- �- � ' FOR APPLICANT TO FILL IN • eucrnNc ��0`7 3 �l� eti nroaess ��Ceriified capy'rs file8 wiih`iFe coun�y `ilding inspeo �--:� BUiioiNc �, t � � �ori�departmenC'' � � � AODaE55' ' .., , .r.� .: . . .. ,;�.�.�. ..,;...,.: �. , , � _ .. _ _ .__._ _. q��,�7��,, Dofe�� �...'. �...•'.�:..ApplitaM....,.-. �•,..,. . . �i ,� • CITY ZIP IOCAUN � �H"77�(�'tIL as �., J �p ' '-�CERTIfICATE OF EXEMPTION FROM'WORKERS' ��'� �-"" "'-�-�� ""�'�/ h� --�--�o�OF BtoGs:�--� ------ � raEqaESi.--•-• /� " �� -�� ' COMPENSATION INSURANCE"�- . .,.�; SIZE OF LOT (� ,l„/ NOW pN lOT �FOSS Si._ w .��� � � '� h ndsection�need not be-comple�ed if 1he peimif is for'one —..-. ---- - �'-� '—'-----.--� '--'--- '-- �-, A:SESS02 . --'- -. -. .� red dollars(EI001 ai less.�.. . . TRACT BLOCK LOT NO. ' M1P BpOK��. .. ' PAGE 7ARCEl � ,_ . / . . ...,�.. . . . ,, ,� �� . .... ,..� _ .. OWNER L" D _ -__NO1��4�7�"Z� MAP . .. �P�� U'�EZONE �o. 05�33 � Pcertify that ia the performance of�fhe.work for wFiich Ihis ` I. /y� n \ ermil is issued,I shall nol employ any person in ony monner - qDDRE55 �i� � Clls ----��-�—�----�� ;Ir-�,/' SPECIAL ��� � � � -- -���� � � so as fo become eubjecl to Ihe Wo�kers'�Compensatioo Lews. �� CONDITIONS .:,. ..,; . �,.,, .. ,. , .. , , , . . , . �., ��.... n1� . . . . , � ,..,, ". _._"' CITY-- FY� ___. "'"_.ZIP_. . 'L�� : ___ '_ .- : . .' " " ' ___".. ._ . . . .. , �...... . - . •- _.. _- . ... � Dofe...�. . : . . �APPlimnt�... .•.•.� . : 1 ..... � NOi10E�i0 APPIICANT: If, ofter making'ihii�grli(i[ale of ARCHIIECT T���'1���/_ -'� ,DISTRICT.. GROUP iYPE...._._ . fIRE . ...PR ESSE�BY. . — EBemprion,'�yoo ebouid bemme�subled fo�Ihe'WO�Aer3 ' -- ENGINEER � ' NO. � �/7 CO.�Nc'STT. ► I Z Compensation pro�isions of tha toboi Code;you musf fonh- qppRE55 �-�j ��b v f��G + �•�O - --�h�� 'Y- • wi�h comply wi�h�soch provisions or thii permi�shall be -�-�- �- ! d0emed revokerJ., . . - �E�� ' , 5'ATISTICAL CL4 ATION , APT. CON00. .�.' . ,.•' .- .,`. '�':'.��.. CONTRAROR NO'�+ LICENSEDCONTRACTORSOECLARATION-��.,, :., ..-- -- --- --�---'-- '-�._'....Q--�� NO._�-� -�� '�_ � ��nA55 NO. DK'EtL UNI75_ �� ��- -' ' I bereby afiirm ibot I am I�censed ander provisions of Chapter 9� nooR[SS � � � (mmmencing with Sec�ion 7000)of Division 3 of rhe Business and __.."' .�._._'_ f�f� -- --- IIC:-.. -'- �-�- �� �] � . � � _ R MA Professions Code,and m license is in full(orce and eHecl. �Fi �� Np.OF ,/7�_ _ NO.OF_ C1A55 �HFCK • v Bx����• �'!� Y ,,. . ���VAUOATION license Number_4�( 1���Lic.Closs �1 ,� SIZE�D S�� STORiES !r� FAMILIES � ONE . . .. . , '/K�ry,1,�'•. /�� . . .. . . VALUATION .. _....: ... . 7 1�f ' ,�. .� 4/�Cti�\��-C��i. ...� . ... '""- DESCRIPflONOFWORK' '_ _ . ` . . • Convaclor Dale � � A D � � j - �i om azempl under Sec. , ' . . ... . � J-�N �C-"^�-- �, - ---....__❑ �� ,' -.. _ _ . . ._ . '• .. , . . . -���,� .yy� ALTER _..... ry ❑ B.SP.C.for Ihis reoson �. . _. USO4�-V/�l���V�S'�'Z7--v . REPAIR ' f��O'��•--. - '-- - �--�-- ..- . ' ' � _. . . . _ ..._ .._. ' .. . . . , - , .. .. ' ""Dafe:..`. , . DFMOI ' a ' . "� ... EXISTING BLDG. i�C �' .�"___. .'. � . - � .. i � ._'._ ., . . Y ,__ �.-�.:. -". .. - AP%.ICANT 7E1. _ y� � . , ��:���,;'.�� �_F� Signalure ' "_.. ._-".�_.. .._. - . FINAL OWNER�BUILDERDECLARA710N _ 9RiNi _ NO.� 7 v� .. DATE--{j����'�8 � ' � -..- -i hereby affirm�bo�I am e.amp�from ihe Con�rotror's licensa r A � � °^ � low/or�he fallo:ving reaso��(Se«ion 7031.5,0usiness nnd ADDRESS ��� � ~ Q�u r.- ) N � . FINAL `-� -� ' '�� � "� . -Professions Coda):. ............_....._.._...._-..'..._'. ..' -' PRESEtvS _gY,_.. � ...... . ,. .,. ., . � a���o�� � . ; , l I, os owner of the properfy, or my employees witM ___ ADDRE55 ' _ '_'.^ " ' wages os iheir sole compensation,will do rhe work and , �(��� �� �� �- . - r �i�•: ` �` 1he structure is nOt inle�ded ar o(fered for sale(Section ����TM ' --�- � -704a,Bus�ness and Pro/essions Code}.'--... : --�--�-- nnoviNG�-- -��-� ��- -. .. -...--' ---�teC�---- -�-• � �� - � - � - - , � --- ., � I,ns owner af fhe property,am eKdusively contracting CONTRACTpR NO. � �j7�� ' , �I - � wirh 17censed contracrors ro construcf�he pro�eU(Sec-._.�._ .__..-_-_._.. .._--.-.'-_ ...�-'_-_....--,--'---._ '_'__- . - �4-. .___.-.___- .. - - . ' lion 7044,Bu5ine53 and ProfeSsians Code). ADDRE55 ' � , � . . �// , � . .. _ . , . . ` Y _ � RE�UIRED- _ iOiAl SEiBACK FROM-.- I .. - - ..-. � ._ '_ '' _' ' ' '_ ._`� �- CONSTRUCTION-IENDINC��AGENCY -��--�� ' � -�- SETBnGK YARp �'� PeORtWE WiOfH - t I hereby atiirm that there is a mnstruUion lending agenty tor igpNT � � � ; ' -� l',� the pnformance�oi fhe work for which thii�Permit is issued -- �P.i.� � ----� ---. -'_-. . .�-'�-- - `-..• --.-.-_. . .. ..... '�-- - :. ..�\ . (Se[.3097,Civ.G�. _ SIDE . , . . m _._-.._ .' _ '_ _ .____'._'_ '__-_ -._ . .__._ 'P.L_ ___ _._._._ � � .. ._ _ __ .. .- _.____.'_.__ '_ . _ .__.. __ _ .'- � Lender's Name � /� . $ __ . .. _ ... _._' .. ...__._._.. .. . . ...�. ._.___ P.C.Fee3 � ll� - � Permlrfee_'... . . IDMARef.M , ' ' � lender's Address /T7 � N � - _ � ' . , � -1 certify�hm I hova reod this applimHon and sfate tho�`rhe ......__ ._�__._.3��.--/� Issuance Fee--- -I�+•J�-, LOMA P/C-N� ��/� '-- .�._. / � obove informo�ivn is correcl.I ogree�u mmply wi�h all Coonty Inventigm+on fee J� � � _ordinonces and$fafa laws relotin fo ilding construction, ____. .._.�_....._.__._.._. . Tmal Fee� � �(✓�� �-. -LDMA'P¢rm:M ' � ond hereby outhorize represeN e this Caunty to enter ' '� upo ie bova- tioned . e r inspection por oses. � � � - / -�s �j - ----- _ --- -- ..--- _ ._ :_ -- ---- - - - - -- - n � � a �V � SEE REVERSE FOR EXPUNATORY IANCUAGE � ' 0 '_ _"" ...__. '_'__....'_'"_—..__..."'.._... _. .__.... ..__.. _�_.. 1 _ � Si9narureotAPPl�mn�orA9en�.-_'_" 'Date" ` _.- _-...-.. .-. .-._. ._1._. . �•, o •� Q� !�o �1 p � Q ,��, -'' ' •�' : ��_p�`''�� � c�-o p � m O .m 9' d �j � � ✓.�, �. � O � '^ 'a0y, -. , ,o �. 3 v p � ` ,,. . / o � n� a ,p .. .f �p .. � �N' p � vl i �j .� ,fp i . b � �"' p . 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