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HomeMy WebLinkAbout06_30_1986 - 20948 MOONLAKE ST ,. . .. ._-----_. _...______.__-,--. ---__..___.�. ._ �_. _ . . WORKERS`COMPENSATION DECLARATION . " -� '`y^�� ��- ��� - -+ �•• J� I.here6yaffirmthat.l�hovea-.�e«�F,�a�e:of:�o�=e�;:�o..,e�f -�-�--�--�--�APPLICAT�O�N�FOR. BUILDIN�G-�PERMIT���-� -��� msv e,or a cerlifimte o(Workers'Compensation Insurdnce, , � -' _ - ' ' . - -� - � - t � � or a certified topy'thereo((Set.3800,Lab.C.)� � ' ` - � - ._. _._:�_-___.� .._; '� ����•= • � , �� � COUNTY OF LOS ANGELES ' BUILDING AND SAFETY _... ,. , .� �,� -• ----- -- ... . . _. .. . . . . Poli[yNo.� -�� � � •-Company �� � �-- �-� BUILDING � �� �Certified co 'is hereb fumished:��+`� '•�-� �:� �� AWeE55 ' Q yg a;� � �, PY Y � � FOR APP ANT TO FILL IN � . Certified'cop'y'�h filed with rha tounty'building'inspec- �'- �-� euuDirvG � �� tion deportmenti'��- ' "-�''• � ADDRESS 1 ! � I .. , .'. ' '. ��.1tl�i- . Y - _ Ddta • � .� . ..�`�APplicant ' � Cltt I - - -ZiP iocAUTr n�al � ��''�� � �� � �CERTIFiCATE OF EXEMPTION FROM WORKERS' ` � ' "� -- -� � � �-- �-� --- ���e�o�s.� - -�•- -- �� NEAREST�--��-� � - --._ ._ -�`-'--'-'-'---�.__ ._...�._ .; � ' ��-COMPENSATION INSURANCE-'• � � SIZE OF LOT NOW ON l0T GRO55 ST._ p' �C l�, � hThls S Yt�ion need100)Oa 1e53.�leied if ihe ermit is fof one � -- OWNER � BLOCK � " �... LNTONO.. ._-.. .. �P55���... � ' .� PAGE, PARCEI i undred dollars(S P � ..P I,cenif that m tlie erformonca of the wo�k for which thiz ADDRE55 - ----J----- ! U�Z�b �P /1/ 3 I \„ ' , , _ ,3,-3 ,,, ,. permit is issued,I shall�nof employ any person in ony manner _ _ (' _ -- SVECIA��-�� � �- - -,-- �-----� -- --- -�o}. � so as�to becoma iubjeu'to the Woiken'Comp'ensation laws. COniDITIONS ' I� . , . , _- cm / . --. .--zir_�.: � _ - - ----;-----. _. .. _..__ _ v , Date � ' -�'"APPLtoM'. . � � ARCHITEQOR TEI. 1 . . ��� � .'� NOTICE TO APPIICANT: If afler moking�this Certiiimfe of .DISiRICT GROUP ttPE . _fIRE . __PROCESSED BY.. I ENGINEER NO. Exemptfon, you ihould bEcome iobjed to�Ihe Workers' --�-- CONST� ZONE � Compensation provisions of the labor Code,you must forth- � W _� � �_ _ 3 . .. with comply•wilh'such provisions or this,permit shol� be -.. ._ �DRE55 TE� � STATISTICAL QASSIFICATION APT. CONDO:-'� i Z � deemed revoked.,',.,.,,;..' . ., .. .� ,:, CpNiRpape NO. . . UCENSEDCONTRACTORSDECLARATION�.��. : . ----._ _.... .___. ._ . . _ _.. __----- ..-----� �aA55N0.Z.�, .DwEu_uNirs--,---- --�-- - --- - _ ur.- � 1 hereby affirm thot 1 am licensed�nder provisions of Chapler 9 qDDRESS NO. ' (tommenting with Sectioh 70D0)of Division 3 of the Business arnl . .. . �R�P �� �. '� ° ' "-'• ' ' '�' . . _..__._.--_ . : ._... '. - -� - Professionz Code,and my license is in full forte and effeN. , C�iy nq5,5 � � --- - - - i--- �.. ! ..�.. .. . ., ,. , .. � , :. . . '.�.;" ,� _"._. SQ.Ff' ' _" NO.OF . ___. NO.OF_.__. CHECIC � _ . -'j .. BK. PG. L� ; j VALIDATION. . ' �- ' , � . - . .. SIZE STORIES FAMILI 5 '-� - ONE", ;��.��'..';' r•,�. . .,, ' : LicenseNumber � Lic.Clcis . . . . . ' � -.. . .. , .VALUATION . � .. ., ., ,: ..�, , .._ •.�..,n . ..Oale_, .. . �.-..... . ._ DESCRIPfIONOFWORK_.,,.. _.... ' _" NEyJ-_.� : Q�_.' _ ._ '. _._-' . Confm[for � . � �.: : . . .� . . �.. ADD T.. �._ __ = Z � �I am exempf vnder$ec. .."-_' '- -.---'---__.._-- -•---__..'_-'--- -__-� ---_.' . . .__. 1 <� _ . _ .. .. , ,. . ,. � n«R O - - - �- =466<�A : �B.&P.C.for this reasan -.--- - ----- REP.4tR-O f�� - � -- ' ---- : - -'+ . _. _ .._ ........__'." Date: __. '�:,.. . _._'- AXI�T�INGTBLDG. NO. DEMOL , . .,�'•�♦J��� --- - ' '' -'- - --. ... ......-"--' ..--- -._ . .___ _ . ....OATE_.-�-.'--�-'--��'.. --'.�___._,..... .n..�..�__,j t Signdture - FINAI . OWNER-BU�IDER DECLARATION ; 1 hereby aif�rm lhot I om e*empt from�he Conrrocror's l�cense -� � ' ��•� ' � �� low for the fol�owing�reason(Section 7031.5,Business and ADDaE55 pqp��� °� . �� �� ' � • ��- '� � � ' Pr'ersionsCode): ...._._. ._ _ . ._.__.__....____. ...____ R -8y � - � .. ..`_ + BUItDING / I, as owner of the properly, or my employees with nDDRESS -',\-., l .I i ,I � wages as their sole compensatlon,wil I da the work and � .. �� ., ��" � '� ioc�urr I �i �� O.�� the strodore is not imended or offered for sale(Setlion ��v� � ..__. .-.-.- ._--.'-'--.- t�,��".'._ --- ---�--_� . . 7044,Bo51ne5s and Professions Code).-� --'-"-�'� MOVING- -"'-�-�--��--"-'..._. ..-..---�-TFI:��---�----. ' ly�-- . � I,as owner of the properry,am exclusfvely controcting COhrtenC70R NO, I C��� ,1 �,� -with litensed tontrocton lo construct Iha project(Sec- '- -.� .-._______ . _ _.-'--_._..�_...�.__..------- : .- ---- - --_---- - ' fion 7004,Business and Professions Code�. ' , ADDRE55 . � � ' �REOl11RED._ TOTAL$ETBACK-F M- - %I �____ - ._._...__CONSTRUCTION LENDING AGENCY " �---� " SET BACK -YARD�- 'HWY-. "- PROP.IINE �WIDiH -;�_-_. ..-- - I�.--�---- i -..-'_- --- .._..�� � 1 hereby affirm that ihere is a conshuction�ending agenty(or FRONT , i � �' ' " "1 -the performonce of-the work for which this permit is issued -..-.- "p.t.---'- ----. -.-- -------'--- ---' ----'-- � --"-- ----� .. -- - ; -��--�---' _..�-�--- � �s��.so9�,c��.e.). s��e . ,� ._.'_ __.. ..P.L_____" '. '. . '.' ._ ._-,....__._._.._.__.._ ._ ... :._.._'.___'__"...__._' __'_..4____._ .�_�_._.--.'J -_ ._.__.. ...___ . . _. _.. ___ Lender's Name i ..L/..�5' ' IDNA Rei.N � � - "� _ ..._�.._ . . _._'__ . '_'"".' __'_"__' _"_'_ _"... P.G:feeS'-'- _ ' _"-' _... PermfFee"' CD .. _._'.. _ _ , lender's Address - ; --I certify ihal 1 have reod this applimtion ond sfaie4hm.ihe _ _' --heuonn Fee-.�.�..•S�c--' IDMA-P/C M -- ' ,'�- ' . . ".i ..�a diheeeby�u�tharizerepresen9atfve�of hs Coonrylto�ner --� Inv=srgaronFee" _'_Y_ TamlFea' --3�•7`'�--.-! �LpMp,Perm:��'-'---'__-' -'.. -. .--� ----�.-�-�--=-=-� 1' upon th b ve-me ioned p o erty f Inspeclian purposes. . , � .. .__ . '_ _ .. _._. _.__._ _�/��y _ _.'___—'_"'_ '_... - _'__ -__'__ .__._.__ . _ -_'. f � /; . _. _.. _, ,. . . _-__ _.__ .. . - /p �/�/�� � SEE REVERSE FOR El(►IANATORY tANGVAGE � � � -_. . _ SignaNre of Applicant or Agem _ .. _ _Dfate �� - _--... _`__ _'_�_ __.__ _'� —�. _.�_.__ -___ .. ___.._. __. ..�_ . .. . . ._.. _ '__ !(�� _ �Q ' O • M�^�_�- -Q I•p� .�--t�i .�,w- -n @_r� o ..,v 1 T '^ '.'i . r' ��... �W O .� � `,v �'� 9 , ., � �O O p n ry.� � t0 •_O � �. tl, . , � p � ��"" � . 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