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HomeMy WebLinkAbout1390A � I.h�s6Y��m ihat�!F�av9 u�cert�fiSotpe A4 Sonsent 10 self ........- ....,...,,,....��■ �'1/�■ ��V�4�'M/��y.��.'`�� ��V ■-��11 Y l'� `._... �..i� '. �{iYORICtR5 COMP�NSATIbNOECI'ARh'fiON x� 7 k _ a ���;'� � 1't bttl terrifredc� �fHereof 5ec.3800 Lcb'C �ce, � � ,. ,AM;., ,,..� �,y� i,.,..._� .. __. ,_ ....�_--- -_ __ _.. .. __... . ,,.__.. . __. � ,:: �. � COtlNTY OFLOS ANGELES � BUILDING�lNb SAFETY`_.._.._. _.._- . Ipau e w a cemficnte o Workeis Com empuon(esuran , .� h 4olk �nlfied co 'is fded wifh x ._ ` _ BUitDMG _ _ _ � � �Y Gertifred mpy i�Inreb fumrahed i . � .,:, ... . � FOR APPLICANT TO FI4L IN I � � .� /�(�(f� ; , . ''� 'the�rn`, bmldn 4ns �DRE55 PY h�Y' � f�- �.�. BUILDING � r�) Q ' ' . � 1 j � , � a �fon depaMm�nl y�.,.. � r:' , . � ADDRE55 wVQ � I � �i 1 stt'.�.Y.�.���.1 ...r..��-�:�. �., .�..�i.c.1 �6���.('�, � S�I _..__'__.. ..r__"'__". ...._...,..... ......., ....... .__._ .. _. .... ... .....,_... .. ... ._. . oa�e �,. n,.,, ,..n�spncn��� :..�, arv zia.._ _ wau�Tr _ � � ��4'Ck'RTIFIC'ATEbPEXElY�PTION'FRQM"WORKER� �st". _ o.: .. �_._.. ._.._.___.._�_._v..._.....�3.�k7FBlDGS --___ _ .�_ pEAREST� � ' i i _.......�., __..._ . ,p,��.�,, , ► : ���„ni�<.._..EpMPEN5AT10N��INSURANEE'�� :. .., SIZEOFIOi � . �NOWONLOT � CR95557.� _��il`"'v'7V�W � N� •., ThlSspition 6eed-noi�6e-corti leted rf the`. ermit�i�fat Pne --..._..._ � ` . . . ^-' �� ,dn 1 � a��).; ... �R ''fl�0 No. . s � S ' nssEssoa , _ , ,;, � _ _ .. ,._. .. buqdrad pllavf �IOQ or le P .p . BLOyCK"�� LOT NO. � MpP BOfJIC'� } , e.s 1 pq�1 PARCEL }. ced�f ihor in ih� q T i USE ZONE tiw' � . _._ . . , i�. ..,. •`t,��. ., .,. . .._..._._'_ ADDRES�s...._. C.% !-�._.__ J'YI-� � .,.GONDIT16N5 ' � y� e erformanc2 of ihe work for wHic6�bls � � ' . . ...,._. �_...,..,.,._ r . '.._,,�_... .. . . . � permH Js,YssUed 1 shal`not employ Gny perfon m� .... .--- �tY......_ C<.l_._ .__..ZIP�. ._ ..-'. , �„ ..�.^ {O ' s6�as yo 6�^�2btn�sv6�ect Yo ih�Wo rs Co nsorrort"t'aws y ; .. Date .'.lr D �7�„r<A pltcan �. � � ...�Q � P . ARCHITECF OR . . 7'EL. ..- �. .... � f NO710E`T4Y V+PptIC1CNL•Jf;'tifter�dkin�"thls CeAificBfe of � � ' ' � � .:,p15TRICT � EKerhplion^lyou'..should becom� eUbjetl�-�to'thE'Workers• ---�-. NGINEER �NO. O .._.. . �- ���Y .i F i ..G1tQUP. TYPE ... FIRE..__.�._ SSED CONST. lONE V ; ,W wilh�eorrap#p with.nueb�provlsiens or ehis, ermt skwl� be -___.. ADDRE55 . .. � t -- �.--. '�4i' j � deemed re okgd.v�sione of .he iobw Ceute.�yotri ust 6... -'..__. ... ..:-. . � �. C �i ; SiAi�Si�CAL Cb4551FICa710N . . . ..i APT. CONDp ''j Z i p t . + .....- CONTRAROR NO.�Wf���(�� �tt' (� ,,.�,� : � � � IICENSEDCONTRACTORSDECIfiRATION :�.�,�.: ..... _..._ _ _._..._ ...._.........___._.,..-tK..�rM`[�DZ..I� � - �- --- -..._ f C1A55 N ���DWEtI UNITS� �Profe by a�'rm lhpt I am licpnsed undef proviaions of C6apter9 �� ADORE55�. (� NO. 7 i t ber menon witfj Sechon'7000)of Divisfo0�3 of tha Business and _ _... _ _...._. .LIG .. -! ��R MAP : , �.:. , � tan g ._ .�y� y ^ ssionEtode,:dndr�yNcenseisinfuYlforceandeffecr. � cm � N����T L7/��� i�0� C11S5 C.�! � ... BK.�..�`� �'."`_` .._...'.,.` '"VAqDAT10N . � z�� �`" . �/`/ ,. I 5(�.Ff. r� �NO.OF NO.C1F CHECK I �� i R t��. SlT V�� • t Y... J .� .•-. .SfZE._.fOO__.StOkIES -.. �FAMItiES`. .:...ONE � � � � . � � YAtua � Gcen3eNJmber .. ic Cl�i � ...:. T�pN _ ,.:_�._�.. � �. �- 'i ... ..�..,,. . � , ., . � _..... .._.. NEW.. I �OO ��... .... 1 �t ��i 1.. __..... .� � a ��.ry.� � � ��,����woRx L ,c , _. _,. ca��a�a� ., o�,a Q .,_ .,�- ,.... . . ADD .. , _ _._ . � �....�_._. AtTER 1 am exempf�nder SecJ._..._ Date:'_}. _� ;�..•", ...'-�._� ExiST�G B�DG._. -.. .�1� � � .. 4EMOl �� _ �_...__.... _ �.__ .,,.:,� .._ _ ._.. , i ? "1 fi ' - B BP.G for this raoson �; � �- , , ,:. N_:... ..._ . ......_._. ...._.__.__ _._._._.�..._,..._._._._ _�.__�: . ._ �. ........_.Sgnci�re �.,.._ _ ..._.�._._._....__..,.�._. _:.�.4'.. fINAL� � _,...,:��.,...�..._.,.. _.._ .._' APPIICANT TEL i OWNER BUILDER DECLARATION . raiNr NO ,�� ...�Z :, . _lhoreby.affumthatt.amaxemplfcom.theCanmacfe�s,license ��.. - ADDRE55 .. . .. . ..! FlNAI',°"� . . ! ! P❑eswa esB�s�heirsolecom'Pensryation.w1ldoPFeYwoskaind '-`� ADDRESS . .__ .. __.... __.__..__� . ... __ _J �r_� . .. .... +.:_''�.���,�'A � �I law for tge followM redsop�cti�n 7031.5 Business and ...:.. .. .. .. ��:'.T i .. .. .^ ,. ,. i �thastrutture�anmmlendedorofferedforsa�e{Sed�on � .._..� . ,:....,..._._.___.._ .... �....._�.....__, ,-'--.,.,;_ __._:___._ .i_.....,., . : �� �a i�if'� -. � �...-7044;-$�sin�-mid-ProfessionaEode}:_ .T ..��... CONtRAROR. -.. ...__..._--.__ ._ ......._NO"--...__._.. . � ' _,. + _.. .i I .��.fi n_'7044�BusneruandProf ssions�Code)PT��cf{Sa9 .:_... �EQUI�RED._.,..YARD�' tIWY_.._:TOTAISE[BA ._�_. .! .�_ ._ ..�_ -.. _�. ._._.. ..�4 .._._ ._ ' s s���`' ..�j . . I�'I �� ♦ • �...-ScTS. '�`"' "CONS�RUCTION�'CENOING RGEKICY � �"` � BACK PROP.lM1E �VJIDTH{ O 9 CJ S".a 7 Ii . I hereby�affi�m�hat there is a constrocrion lendl/g agency for fRONT . � �� � � � � � . -'��.- ._.1he- erformanceof-Ihework�-forwhkh-Mhis reMliaiesued�-_M. _-p.i,....___. _.s.._.. _....._. .,_...._. ..._.,._... ....__._. ,. �.._I �_'-'_. _._..._. .--..,._- ,-•'__._. __ �__. .,. {Set.3097._Gw..C.�_..w..<...__._... ._.._.. __:...;.._.._ ____._.. . SIDE _.. ... _�. ..� .. � l�hVl Ref.t "'...:-..-.�.� __�. �. �___ . � p P� � P.L. � . . � _ _ _ __ ; � I � �tender's Name . - . . � � i $\ obove i twmorion is co.rea.i R�ee ro com i wHh all CAunty _ ,�� P.G Fee t e _.._._ __,, asuomnce�e_,._� Yf .10MA FlG1- _ � E._ .' a9 PY Investi WianFe ..._"„'""' i...... - . .�^_� l.� Lendela Address � � l.tertit Jkxit.Lhave.read ihis.a Ucotlon cndsfateJhat the . ' '�, � _ordinancea end State lows relating fa bvjldmg conalruction. ._..�... ,...9.., __ __:.._...-..._....._ �b4iee.:_.. , ��...__ ..�. �pµq..perm..K._.___�_._... ..__.. :.��- --_,._i._,..__._.�..:-.__....__?.'! �'. u eieby a � ' repreaentabves oi t6is Couniy to enter � -� --- - '; u n e a e-m tioned property for inspectwn purposes � � � � � '� � � � � �� - � ' � � �.`h��_��_��,_��.�. __ _ ___ ._ __ _ __ _ `�� -- __ - . . SEE REVERSE FOR FXPUNATORY tANGUAGE � i f �- � � �� --.._..Signolurc�ol Applicant or AgeM .-..�__.___..__..��....._ �_.__..._,_.__._.__,..__.._ _.. ._..._. .. ._.__:. .,.__,.,...� ..__........ � ! .,_ __._. ._.._.__. .__ _.....�"___ .._.-' _'..... ._.___,m I . � .. . ' . . . � �' . ' . . . . . . , _ _ _ _ -- - . _- -._.._..�_________� _�__ __�� ._.___.� ;PLANS TO APPLICANT �- INSPEQOR'S NOTES . . ,,AW�IER BUILDER DECLAR/�'�'ION.� � "" I h 6 1f' �h t I t f t C�r r ' � xo'c .. � s:.- � ��^a RetVrn� � � ` '.�� b ''.-: �" v.. ' ,�..:: t�i- �y:. . �'Lif;anse Law'for �he #allow7�gPie son �SOt.."70�1.5g } � .. t,.,u.•.: , .. �'� : �:�- � i' F . �. . a £ „. .-.... .. , , . ... ,;, � � ' Approvad ��usinessan��ro/essionrCode•Any,atyorcpgnlywJ�icb, . � No. DWa �. ^'�'No' =�".�.Dafe :.�•���-•� ��'�? +' . .,... ,`.::.'���s:�._�`'-%:f . � reguires a permi2 to coxstrud,alier,improue,demolub. � ` ! ' y.r.;�\-i..i'��r.i �� �.�fV Ir.. „'�.�.�. ..,,.;�,.., f �ld _,�� L � -f�'?;r.� ��"tractor'sLce���Cba ter /(rnmmgnnn�� �e�. � � � - 3 . �, j jnK .�t.._:�� _. -..' n f P � _ - -.._ � __ _._._ . ..�. . .-_ -.�.. -' --' t' 000 Ihvu'o 3 t aainessand r seon.s � .. �. f '. r � �..��i� �...... � f ;� Code or tbqt beis esem 1#be rorrr a+�d tbe basis ontb¢ , i . f-,1� _.: _._ _ -_ _.__t . . _. L_�� F �� Q3 _..._._. _ _— . _. : .,_,, ,,._ . _ _ __ .. . � . , -. .. . -� _. �. `� � alle8 Q ..,Rn4tt.,Ay+ vio �,.n:of SecHon], 1.5�bY �.� , � .�y�:�squ[�$Na . '.-�D�afAPProvad'�`. ____,.� �c: . .�...--' i ,,� f J I- anyoppllcantforPpern�itcrtb�ecp.csbe.applicanttoacivil _ __ ' . t^���� Approval� ' ' -� .pepalty of��aatmoreJbari.�'ave bandred dollan(JSDO).);; � ��''' �- �� �� ❑ I os owner of the prope ry�orm 6m ftiyees:Vlt�r ' Waier Cert ficate � ' �� ��� .,-:�_ i� ( _ �pges os h ❑sole comeensation JI do ih�e work,ond � _ _.- . _ _ -- ,_ ..� _,-.�. _`--�:, + - t � t��� -- �'�wsaa�ess a�nd's notessivn�ode�ffb6 CinatracF ,�t >04A� ,' F�ealth..Qepsrr.tmenL--- i - .� ( " �- h�., .� 4 � �' � gr'�Xrce�+ze � . ;r.:, .. . ,.�., 1.'- 4.__ 1n ;, b��v�th�3��ebodoe�sroperly.wbqbwlds _ � � . y ,re Depanment.,--- ..._ .�. . . - . . p y �be ljor �" ... .,� i ,-�.. __... � ., � r .. . . _ '- F aEb ioor r�s¢ � q p vrded tb,a{ytmcb-im- � ..,� �"--�. " ,.;:psovements.:ase�atot�iqic7ded or.offered;for;sale.,lf, . - i Grading � i � t". Y, . . i/ , �;•�1 � , � `°.! _��� ���bbweuer;tbe,�iuildragotirripr�auemsntistoldwitbin.on8 - ' �'.:;__. . _._._. . 1._ ±,. ..__. .. _ _ .. - • ..,: • ll , on bbc euiu¢nbutlder w�fl ba e � f3eologuaL: i=� __�::`... ....-� , ..r. '.`� . �'c,7. l � ��� t ia i. ,:�,�� �„f t (�..,.�� r � H- ���burdexjoJpravirsg tbat be did sot bu�ld�or'nnpmve"for ' PF�1 cseriaC Protec�iort. - - f -, �. . . .;... L , �. � .s' .�.��} uftatej .C� � r i_,r, r.. �"..._. � � .4 ....��. � as�: � d u ose purpn�c , cwf lns ec(ion�., �., ��.. .'., � .,�..._.' i .__.-,_1 1 1 ' 1 . �v_,�� �'�� �i�wner of the'�roperty em exclusi ely eeNrat- �. _ ( 1( PY) . . �.. � ���. � in9 �h 7 ce�;ed o tractqrs fo mnslrpc�t�e ro�ect Set: �� - •�- -- - � 7 B ��ess asd Projessaons Code T/�e Coxtra�mri . S e � .... Lue+rs�Law,doea�oi ap¢Ly eb a�i owner oj ropertx wbo e �. P P Idin � �'. .. '. I 1( YI( 9) .� ; __ F _ '' --- -ljiitlds os smprooes tbereox and wbo co�cu jar rue/i . t �� Lot�Drama eonr We < ..' ..,_ .Y +..._...- � '.,. `V � . .,. •.� r�''9rojecla`witb a contr"artorJsf,,hcense�I ;ant,to tbe . 9 . . , -'- '-; . . � . :; .. �. I `'- i , . -�\ f -� �-..Cbnirxtori L'ueas2 Lasuj - , .��::. . -�_. �_� i �. ' i,-. . � F� ., ... __.. ._.,. .� �.:..� _ .�_.___,.__ _,. � _.-_... ..._'__ . ..___ ... " .. .� � Parking §c k I ..' �..;' .... �. � � �I am exempt under Sec B 8P[.fo�tF�is � - . . ,..,��: ,.: .. . a ..�, �__.....--'.._.�._. _ .__..._.. ...,:;�n �„.7,��.... ' k. . �. . .. � � .,: .., . �n ,.' reason � . � � ,. .... . ! .l:.. ,_'�i ( ka r �:j� `r',...= ` t�. '_____. .._...__'__. ,. ... .._._. ...__'__...�.,__.._.�._. � .. � . �; :: .. _ . ... ._..._. ..�. ._. .. '�. ._.. Date Owner �� : :: ��� a ..�—� , , � ..,, _ ._'___ ' _ ,. ... •��� , �-� � -'�� .. _ ._ . .... 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