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HomeMy WebLinkAbout0883A 1701A (6) Y WORKERS'COMPENSATIONDEPLARATION ._ - _... ._.. ._. ._... . .....'-.._.._'—'- "' '- � --..__.. .. _._..._ .�..._Y. ....._ . ......_. . ___. . •. . � , -„ . .�. . .. ., �-'..'. � . ' •insureborafcertiftote�of Workersr�Comeensato�5,�=�;o�e` �����-���������APPLICATION��FOR �BUILDING- PERMIT----���� �'�. _._ __ __ _. _ or a cert�fied cop'y thereof�Sec.'3900,laki.C:) ' COUNTY OF LOS ANGELES , BUILDING AND SAFETY � , , , �.. � ' , _. . __ _ _, Pol q No.'�4 0?40 Company� -�� . -...-- , a ertifiedm ishereb fumished:.r� . -. ;� BURDiNG \(�'00��1 �� �� � py v FOR APPLICANT TO FILL I nooaess oL , �ertifieiJ copy is filed viith the counly bvilding;inspet i"� BUitDiNG /20� i ' ( , . . , , � LJ tivn depariment. `" ' ADDRE55 ! _ . - ..� ,:.. �,- ,,, ._.. ' ' /�/�'A/�/ r_�...__ _ - � D61��,�,.Appl¢aM � � ' . CITV /'/'�/V/��... "LP IOCALITV � �t . _. ... _ i ..' ..`� TIFICATE OF EXEMPTION FROM WORKERS":"'� --..__. _. ._ ._-_-_._..._. �.. NO.OF BLDGS. � nIEAUEST_—._. � ' .. - � COMPENSATION INSURANCE � . SIZE OF lOT NOw ON LO7 CROSS ST. _ � O.N� � i '�_. :...��.. ... . ..... (Th�is�section rieed not be�completed if the permif Is for one --- �._.: q55E550R_,,. ;,, � -�- '� �- '� �� '�-��� � _._..._....._... .. ' __ _ ._. ._. __ - hondred dollors(b100)or lees.),, �, ,,. ,., � TRACT BLOCK LOT NO. ' MP.P BOOK� � ° VAGE: PARCEL I I tertify,that m the�periormance'of the. � � - �---�- J . � ,�TEt. 2 J -- -- �i� SPECint 1- 3�� .•.:� , � , ,, owruEa �l �y /�OULI . N d � USE ZONE �+P work for which rhis NO ' permit is isstied I 5hall nof employ any person in any monner - -`�� � � �� a -�- A ES - - - --��--�-' p CONDITIONS ' ' so�as lo becoma sobject to the Workers Compensation Laws. s �� Z�P /� � � - - ��� O Da�e. ,�.� ..... Applimnt..:. , . -,; _ . .. . ...._ Cltt - - - - - . �. . NOTICE`TO.APPLICANT If,`affer�rriakfn this Certificete of ARCHITECiOR ��• _DISTRICf_ GROUP TYPE _._ _.FIRE _PROCESSEDBY, 9 ENGMEER N0� CONST. '�ZONE �.G EXemption,�yoo'shoold become•sub�ect ro'�tha Workers' --- -..����-��� -�--r� � �W Compensation�provisions of tha labor Code,yov must{orth- qoDRE55 - -��O--� � - ��-- ��� �� -' -� -- -�.vi with•tomply��wilh such provisions or this�pe�mtl sho�l be . - p TEL �, S7ATISTIG4tM551F TION Avr. Co DO.. . 'Z deemed ravoked:,, , � ' � � � ,,.,,,., ' �..'. �J� � _. _. .. .. .. . O . __����:_ , UCENSED CONTRACTORS DEC(ARATION. ,:.,� CON �(�/ryr� i� ��� . `aq�NO. ON'ELI.UNITS - I hereby offirm�hat I am Lcensed under provisions of Chapter 9 �7� I I I /� NO. ,. _, p ..SEWER MAP . ; (tommencing wilh Section 7000)of�ivision 3 of the Business and . .. _ . ' "" OO ����� �-�lJ �- � � "" "' Pwfessions Code,-and my license is in full force and effecf. dN �.Sp �� CLASS -� � BK."� -� - -'---� � ����� i�-'��� ��`VALIDATION� � �. �,�.�� ��� � ., ,.. ��,. ., . .. �. SQ.R./O_l�' NO.OF NO.OF CHEIX . � . . /fQ[''j�]/y.�t � �'. __ _ LicensgNJmbefSQ.�U.—���•Cldss� 5¢E -� STORrtS � � FAMRIES� �- ��ONE � V TION � . . � ,.... . . _' �'� DESCR�7TION OF WORK..T�QI/J -N��� I�/�l �yy�m ALUA _ NEW. - Conlr� � ��ODate� A� � s�(/w� . . , : . � � _ ❑I dm exempl unde�Sea . ����In � I. C -�O` " ' " ALTER � � `�a�t 3,A ... ' -- .. � :-... .......... ...�.-�. � '. _ __ ._-.'._" � � 8.8P.C.forthisreason . � C � REvaia_.❑ - .f.. . ..-- .- _.,._.._. ... . .___...�.• • •-•�GJ .., . . ._ _.____. _.___ __..__Oa1e: ..... . , .. USE O � � DEMOL ❑ � ___ ._ l a a:�1�� _ , EXISTING BLDG. ��'. :� � ,.. � _ _.. _... ._ FlNAL I O II.1 9—H 7 ""'-Si natu�e APPLICANT 7EL. 9 �� ���-��t rn�p� No. OWNER-BUIL�ER DECLA ATION PRWT ' ._.DATE - - -��- .-��� �� --� -���^- - /G _... - (J O� /7 /� - -I hereby affirm that 1 am e.empt i�om the Controctor'z License PD�+ O� �1 I (7 G1S OO p FIN �' �- ' � " ' � ' � p � :.�� -- .' Law for the following reason(Section 7031.5,Business and � � � __ _ , � .._BY _. , . __... _.. _:� .,. ... . -ProfessionsCode): .-.. ..-.. . ._.. ._._..... ._... .___. . ppE NT . �. ,-.. � B���o�� � � -�---.. . I, as owner of the property, or my employees with ADDRESS .. _. .... _.__— ._ � woges os their sole mmpensation,will do the work and � � , - .�� �,Q A . _ the srrucrure is no�intended or o(fered for sale(Section ��`��TM ,_ __ . .- -------7044,�Business and Vrofessions Code): --" - � '--� MOVING. �. . . ....... . .. ..TEL ' . . . -. .._.._ . _.. .__ .. �• • • •�1 I,as owner of the property,om exclusively contracting CONTRAROR NO. � ' � � . '.--'.--"- . _._ . . ._. .-- - i -�--with�licensed cantroctors to construct the prvject(Sec- ' " � ADDRE55�- -.. . �'-' - ...-- - . ...._..-'--'-� -� --� .� . ',.�s.,• ��._..�.�.•..5�j,5� . tlon 7044,Business and Rofessions Code). � �- --� � � �'� �� � -�� ' �� � REOUIRE�. -..-iOiAlSE1BACKFR M. XI � � ' - -�� - T ' ----�--"`�-� 'CONSTRUCTION LENDING AGENCY"'..."...' "--- �SET BACK -YARD- HWY PROP.uNE WIDTH.. .... ..... . -���-.- . � .. -, •�....--� ' • � •��5 O��. I hereby affirm that there is a tonstruction lending agency for iRONT � �� �� " " �`� O � ' ' � . -�he performance o(the work for which thie permil is issued -�- � a.l. .. _. -- - -—- .-... ....--"' .. ..... . . ..... ...�'. ..... .. . .. .. -�.�:r - �.° 9� 6`8'].-,-., , (Sec.3097,Civ.C.). SiDE � . � . � � ------ �- '--- --- - -�---� -_. � :..., .. .. . ... ...._i m '_ . .._..__......._._ __ ...__.�_'__..'._ ._.... P.L .__ . � . . � _. ._ _ � Lender's Name � iDMA Ref.M � � � � .......__..- .__... ..'__' . ..___ . _. __.. .. . ...._ P.C.FeeE ... . .2 ... . PermirFee .._ ._ . ' .. ..�..-. .. .�, � - Lender's Address • ' y �-y� � J te�lify Ihat I have reod ihis applicotion and state that the -. -_ ._-....-._ __. — '. . . _ issuonce vae. _..��.v-V . �OMA PiC N ��--- --. ,- ..,..... ' . .. -�� -- . . _ i � obove informotion Is co�rect.I agree to mmply with all Counly invesrgoi�on fee t—�� � _ I i ordinances and Store laws rela�ing to buitding consnucuon, _____ _ __.___.. _,___. __._.__ ioia�Fee --��S•-V "- �LDMA-Perm.N�-- � ____.._ . ._....._ ... ._.. .. u and hereby aulhorize represe tatives of lhis County fo en1�r ' � .upan the o ova-men�ioned operty for inspeclion purpases. _ . ,.-"-.... .. ... __... ._. ___-___-__ __ ; � ..._ .. . . . .. . .. ._. ... . . ._-' -- - . ._.. _ . _._. . . . -- -----� ----._ _ --- a SEE REVERSE FOR EXPLANATORY LANGUAGE . n ^ . . � . .. .._ . .... O . .. Si aW 1 genl " "_ ____--Date._ ........_ ._' ____ .. .___._". '_ .__ . . ._' _' _'_'._'_ __. _�_. . .. . .i / ,�.. . _ o o- • ' ' ,� " -� i , � T �.. a � � o � o ;� 1 � T'0"_ � . �' C. r, ^9 �a o� a .o ? �m 'Y. �' O � o � co o•. � .o o , .a, o o ��. J� �o. `° o v i i. . 4. � . 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