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HomeMy WebLinkAbout1390A (7) � 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 Qoll4 �nlfied co 'is flled wifh x _ _ BUILDING _ _ _ � � �Y Gertifred mpy i�Inreb fumrahed i . � .,:, ... . � FOR APPLICANT TO FI4L IN I � � .� /�(�(f� ; , . ''� 'the aou bmld n 4ns �DRE55 PY h�Y' �� f�- �.�. BUILDING � r�) Q ' ' . � 1 j � , � a �fon depaMm�nl Y� i rr. , . � 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-nol�6e-corti leted if fhe'. ermil�l!fat Pne --.-..--- � ` ; ._. . _,-- �. ... ' . ._ Taacr 'fl�0 .. _ _�t .ssEssoR-_,; _ _ . ,.;,, I .. buqdrad Ilavf �IOQ or le Pn ,., p,. ... � MAP BOfJIC'� } , e.s 1 pq�1 PARCEL }. ! �dif 'ihot in ihe; erforman�Cd _- OWNER ', � � . 1'''/-�s S USE ZONE � ; � � 1 BL LOT NO. � Y., p of Ihe work for wHic6'fbls� , '�'' { j . . ____ �....,.SPECIAI.. a..___.. 0. rmH Js Issued 1 shall not em loy Gny perfon m ony'mtlnner � _[(, ._ i i. ��-. . .. .-' .--.-. .. '. I s6 as yd 6A'12�btn�sUb�ect Yo th�Wo rs Co nsotrorY laws. � > �S . " !V { .. � .:r D �'�..� � ��� �� � .. . _ CIDDRES''s. ' . C/-l_..�. _..ZIP.. ._ � :,PISTRIR ..GRQUPI..,.,._ r . �.._,� ...... _, ` _._ ...� I �� . ..,_. M. � Date � APpltcan � � ARCHITECF OR .. , � � 7'EL. .._. � .___�._PR SSED 9Y .i O f NO710E`T45�+PPlIC1CN7 If efter�ndkin��thls CCAifrcBfe of � NGiNEER � �NO. `` y I E�erhpl�on;�lyou'��ehould be[om� aUb�etl�-�to-)he Workers -'..�_. �� WNSY. ZONE �/� ( . pIY withy�sucb�provlaicns Dr �e.�yOtPi ust:fOrth• . ADORE55 . ..� �. c c F STATISTICAL CIASSIFICA710NPE •, � ...I.. APT. CON� 1� deemed re oked.v�sione of the iobw C .....^I� be ____.. � O ..- -- �- �`' � `�"� 'i ! _ wilh�corra ,......_,, . his, erm t sha CONTRACTOR . . .:�. � NO.��?f�'f 7 t' . Dp . �� ! , • .,�:t x . - . . . ._ . ._.__ � .' _.__' '..... � � IICENSED CONTRACfORS DECIfiRATION .: �.•�. --- - ._.�..- .-.-....-..__--_.,-yK..� O. � 1 M.(.J_,�{. C1A55 N ��DWEtI UNITS� . �Profe by pff�rm lhpt I am I�cpnsed undef P�oviaions of C6apter9 �� ADORE55�. (� NO. �j •�1[pJ � , i . (tanmenong'witfj Seclion'7000)of Divisfo0�3 of tha Busi'ness and _ _... _ _...._. .._ .�y� y .LIG ... ^ -! ��R MAP : • , ..:. , � z , ssionE tode,:dnd r�y Ncense is in fuYl force and effecr. � cm � N����T L7/���- i�0� C11S5 C.�! � ... BK.�..�`� �'."`_` ; _... �� '..'VAqDAT10N . � s `",.�.+ . �/`/ ,��'>�� � � I 5(�.Ff. r� �NO.OF NO.C1F .CHECK ' � , � t��. SlT V�� t ... J .� .•-. .SfZE-�.fOO__.StOkIES -.. �FAMItiES`. .._..�Flp �i I / ' � . Gcen3eNJmber � ic Cl�i ,.,,,.YAIUAT�ON °� � � � ' ,.., ..� .,,. ,. . ,.� �. . ...;.._ �. � ' L .�� ._. � � .� , :_ __ _ '`� _..... .._.. NEW.. .i � 7 _ ",��.. ,a-I �t ��i 1.. __..... .� I ( C�onnQ � W�i,(,t�/ ,�_� o[sca�vriorroF woax noo 1 �� ' , --,_..._�_m. _.___ ador � " Date ._ ,,....�, _ ,....�_._. AtTER 1 am exempt�nder Sec. ... __. _. _. .�__.. . . . . ._:Q ,,. a ..i � v'. ? r� `.- .o.i r � . . � ;, � � 8.8P.G for}his taoson .... ._ ._ . .. � � � REPAIR .:Q .-:; �.. .... _ __. :,,.:,� .._ _ _... __�_ ._.. ._.. __._..._ .Date:"_.. _r;��..��� � � USEpF ,.(� I� � .. 4EMIX � � � I E%ISTINGBLDG...._._. ...._.__.__ _._._._.�..._,..._._._._ _ . ._ i , , __ . : �:_. � _,;��., ,_.__ _- ; ......._.Sgnci�re �.,.._ _ ..._.�._._._...__..,.�._. _:.�.4'.. .. fINAL � � � ;. APPIICANT TEL i OWNER BUILDER DECLARATION . raiNr NO ,�� ...�Z , , . _lhoreby.affumthatt.amaxemplfcom.theCanmacfe�s,license ��.. - ADDRE55 .. . .. . "`! FlNAI'''�..'�' . . � �� ! � � p❑'�'Swoease a��iF�a sa�leco°p52�C�n 70311doPheY�u koii�d _-'�. ADDRESS . .__ .. _.,.... __.__..__.� . .... .._ _J �r_� . .. .... +.:_'`�.���,u'A � I, 9 F� .._..� . ,:...,..._.e,__e.._ .... ....._ .'. �-"':.�._ �_____._ .i_.....,_ '•_. `_`�_Y.'if i �tha strutture ia nm inlended or offered for sa�e{Sed�on T ....., �C�r�R�. -.. ...J........'--.._ ._ ......,_N�"--...__._.. . ..� � � �� � �..-7044;-$�sin�-mid-ProfessionaEode}: ._.... . MOViNG� 'fEt .�_.__. __...___..__. _ ...._._ __.,i__,_ . .. _....__ .. ..� , . 1 as owner of Ihe prOPeNY�am exduErvel�[�f{tin .:_... �QBACK. .�..YARD�' tIWY_.._:TOT P�B IttJE� ._�_-�VJIDTH i '�_ ._ �_.._._ -.. _�..__._.. .�4 ..___ .__ ,._� ` J E1 7 J�..��� . . i ..with�licensed�mrrtracrors ro mnstruc7 tha Y o ct Sar y •��„�S { fion 7044,Busineu and Professions�Code) . � � � '__,_.____ g _ . _.. . I hereby affiim�hat t�N�he eTis�a oFnstr1�Gon I�eoding agency for __M. _o� .. _.s:._.. _......_. .,_.:..._...._.,._...._._....__._... �.._I �_'-'_. _._..._. ._..__- ;.'_-:._. __ � ,�9�8 ,a 7 �,?I.. I .-1he-performance of-Ihe work�-for whkh-Mhis permll ia iesued -P.i.��-�--- _ -- -^ - � {Set.3097 Gw C.). � � SIDE '.� �� � _..---�..____... ...__..w...<...__.__... ._.._.. __:...;.._.._ _.___._.. P.t. � � . � � ��.� _..._...._ _ . . . -._ ._ � �I � tender's Name _.. ... _�. ..� _ ...._.,......_._. .._ .� _�. _ I.. �` .i � Lende�aAddress...__ .__.__..-RP.._._.___._ . ..__...� . .� p.G��Feei _..__.._.._._.. __.�3eswmnceFe_,._ ] . �� .. Yf. ..tOMAFlG1- .._ . � E... ,, I � 1 ... 1 I _ I ; � l.tertit Jkxit.Lhave.read ihis.a Ucotlon cndsfateJhat.the „ _ .. �. � above infwmotion is carect I agree ro comply wHh all County . mvestlgmwn Fee . . � . . . � _.�- � � _....___. �'. _ordinancea and State lows relating fa bvjld�ng conalruction. ._.._.. ,...__.., __ _._:.._...-..._....._ �b4iee.:_.. __ :�.. _, ..�. �.pµqaerm..N_._.___._... ..__.. :_� _,._i._,..__._._. '._ .! _ u ereby a � ' repreaenfafives of t6is Counly to anter � -� --- - ', u n e a e-m tioned property for inspectwn purposes � � � � � � - '. � ��/�.._ :..__ .. . _. „ ___ .....,_ . ,. __ --. . _..T _ .. .. Z-�� 1N _,.._.� . . . . `� . � . . _... . __ . .._ .._. ( .. . SEE REVERSE FOR FXPUNATORY tANGUAGE � f �- � �� --. _..Signofurc�ol Applkant 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. � ` ! 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'� �, work ond ealth..Qe sr[tment._.-- ��.�'.i..__.�,.......� -.---;,� ' _. � �.+^.�'. +^,\ ..` +.�j,aw does Oo a luto aa�oumer o��o er1.w�� 7UAA� ot e __. , �he �ryctpre�s not 4ntended or offer d�,for sale C � P __ Euszness and���t� �' .. aati�gr:s�.rce�s . y.' F�e Departmeni_-- ' , . . . .. _ ., ._. .__.. . . . _�' ._, , ,P P 6 Q b ljor � __..._ . .._. - - . �` . . ... .h��� o✓filf rd �'thereo+f,�1vbo es __ ves do saFb ioor� ¢ �.,� �,.-c�� i �. : ...__.. �,�,:, i r� .. ,-, ... _.... .___ _ . . _ � rr.:, . �, sbrovgb,:hisr�ow� remployeas,lProtirded�tb.dt�smcb,im- � � . ..,� �: �"--�. . �- '- " ,.;:psovements.:am atot�iqic7ded or.offered;for;sale..,lf, . - i� Grading � � �' . �.., ;. Y, � i/.";' ;�1 � ,'i{ `°.! ,��� ���bbweuer;tbe,�iuildragotirripr�auemsntistoldwitbinon8 - ' �'.:;__. . _._._. . 1._ ± . ..__. .. _ _ .. - • ..,: • ll , on bbc euiu¢nbutlder w�fl ba e � f3eologuaL: i=� __�::`... ....-� , ..r. 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