HomeMy WebLinkAbout1109A 1110A (8) � ���./,•,VORKFRS'COMPWSNION DFQARA�ION "' ' '"
� � hr,reby nffirrp ,h<,,� �,��P a cer�ificate �F consent fo s��f APPLICATION FOR BUILDING PERMIT �
insure,o a cr.rtifirale of Workers'Cornpensatian Insur�nce,
or a cerhf:ed ro thereof Sec 3800,Lab.C.
73L+�905-2�/9-OOQ4 Na�OriWidE 10�B COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo_ Company
� Ce�iiFird copy�s hereby furmsh�d. FOR APPLICANT TO FILL IN �1URUING
ADDRESS 715 N. Feai:hen+,00d Dz'ive
�� Certrficd r.opy is filed with thc counly budding inspco- gUILDING /
tion deporimem �DUHE55 775 N. �reatheYtaboc� llrive _ ___ ___ ______ _
Da�e 6-19-86 APPl�cnnt '�'I� �llVDE•[Q GRQUP uTv Dl�nd I3�' u�, 91765__ �ocaiTv aY' .
CERTIFICA7E OF fXEMPTION FROM WORKERS' NO Oi BLDGS NEARtST H1 kt Knob & Golden S rin S
COMPENSATION INSURANCE SILE AF LOT NOW ON IOI CROSS 51 5 P g
'___. _ _
. ._ _
(ihis section rieed not be completed i(the perm�l is for one . AStiE550R
hundred c�o��ar5($1�)or Ie55.� INACT BL<7CK IOi N:: �} hMP BOOK _ _ PAGf f•ARCFI
`i'kl� ANDEi�I GROUP '��967-954 usi oue r.uv .�, . . .... �_
I certi(y�hat�i ihe perlorrnunc�ot the wo�k for wh�ch ihis UWNfR � NO ��,J Np 1�1,3-_�j�� �„
permif is issued,I shall nof employ any person in ony maizner ADDRESS �.�.BOX 3329 SPEf.in� � � �
so as to br.come sub�ect to the Workers'Compvnsniio�Laws. U7l'1) CONDIIIUNS __ Q
� ��Tv Covina ��� 91722 u
�xfe .—'_APPl�cant—' — ARCHIiECI1� � TEl �_ O I
UTICE TO APP€ICANT: If, nfler making this Cerlifimfe of 1J�Ve �'JZc'Z. �� �4.7 4073 DISiRIGT GNOUN �c)NST �INf E PROtlSSCU BY h
ENGINEER � N:) / �
�emp�iori, you should herome sub�ec� ro ihe Workers' ��j i � �
1.0A�,VP�50��on�J�OVISIpPS pf lI�P.����,c�dP,yo�m�•si�onh- nooaEsy 314 N. First I�tcadia 91006 ,/.-:3 � /''✓ _ �.� a
with tornply with such pruv�cions or lhis pe.rrxiit sfioll bc � - - - �
deemed revoked: `I'HE IINDEL�T G�IIP r�� SIAiISiICAI CUISSIFI('/�TION j nrr conoo
CONTNACICN NU
LICENSED CONTRACTOkS DfCLAkATION I IC CIA55 NO �� DIYECL UNI75�
I hereby affirm that I om licensed�nder provisions of Chapter 9 ADUkF55 �5 i1��OVA „�,371580
(mmmcnung wnh Sruion 7U0i1,)of Division 3 of the Busmess and ��� St WER MAP
Professions Code,and my Ilcense is i��lull Force and effect. CITY CLA55B �yK �,C VALIDATION
S" "1446 NO OF NO OI 1 CHECK
License Ni�mber �71 SR(1 Lic.Closs � SIZE STORIES hAMILIES ON�
`I'j� A��,`'[V Ci�V� 6 -19-86 D(SCRIPTIONUF WnRK Single f_amily ryEyy 41 VALUATION
.i i,��,
Con�rocior vote � S j4 Q00
nuo
�I nm axempt under Sec CidYt3 E 470 .� " � �� � � f
.. ��
AIftN �
B BP.C.for this reason—_._. � x � � � ' � '
'_____._. . . . ..""_'_ kEPe:iR . ,, . .
Date: USE O' � , I
—'-- F.XIST�N<i BIUC� UEMOL e... i ,. �
Si9naiure AFPLIf.ANI TEl FINAL
OWNER-dUllDFR DECIARATION PRIVI - � rJ�I1P NO DATE I--L�-�� �;£•,� .-"'�;�'
I hereby raffirm ihn�I am azempt from�he Contrncro.'s License � '1�]pVC —
�nw 1or Ihe following reaso��(Snrtion 703i.5,Bus�ness and �ODRESS FINAL �J /`.'�'y���
�fessiwis Code): PRESEVT , BY � (�'� � .
I, os owner ol 7hc• ro 1 or c p y Bl11LDINC --
p per y, my m lo ees with a[�DRE55
• wnyesas iiieir sole compensa��on,wiil tio fie work ond �
ihe struclurc a not mtended or offered for salc(Sr,Uion �n�ALIiY � �„ ' -' I � � U I'',
70dA,Buainess nn�l Professions Co(1e). MpVING � �EL �
� I,ns owner of ihc property,am r.xclusively corifwcting CONTRACTOR NO. {j a i � • u }
w��h I�ccnsed contracio.s fo construoi ihe projed(Seo qDDRf55 "�� �'� - `
tion 7044,Businrss nnJ Profcisions Codn). � °�•�-�^li�1
NEG1UIRfU TniAI Shi(;ACK f M XIST ' ' '�' ; '" ,
CONSTRUCTION IENDING AGENCY vneo Nwv • �
51iBACK PHUP LWE YdIDTII 1 � , �,( ���
I hereby offirm thm ihe�e�s a constn,u�on lend�ng agency[or f uUNT ,t ,��., !"" `����
ifie pArformance af Ihe worl.for whirh ihis permit is issucd PL __ " ' ' � � `� . �, •
(Sco 3097,Crv.C.) SIDF _. __ � .'. !� ' ?�O
�^ Continental Illinois P� ' "
- tende;5 Inairie �u,v�n R��.s '
`� 231 S. LaSalle,Chicago IL P C.Fee s 231.16 � �
� Lender's Address_,_._._._____. ...._ . Pr�nii Fec '
r I certil ihai I ha�e reud rhis u lication and sta��693 10.r)Q '
y vr� iss���«Fe�• io^nn vie n
a6ove informntiun i corcr,U I ayree�o comply wilh all County Imeanqu������For
ordinnnces anr e lows rFfatiny to building construUion, loi<d Fee • W;AA Pe.rm.q
and hereby i ize represemo���es of this Counly�o enter
;, upon the o in aicd property for inspection �ujrpo}Qes�
:r' — �d/O�
SEE REVERSE FOR E%PLANATORY LANGUAGE
Signrnu.e nh ppliconr or Aqent Dn el "'
PLANS TO APPLICANT INSPEGTOR'S NOTES �)Wy1,H-I;L111.UISR UItCLA12A'I 1OV
I hcrcby affvm that I um r.xemP�irom the C.v;':u�til':.
To: Re}umed LICl415P. Low inr Ihn followmy rcrsun� (St±<. 703��)
ApProved - .--- IJ��.�mr.�eaudl'r-n/rssanr�xCudr:Ar{yci(Y���'cmant}•xobiilr
No. Dale No. Date , rrr/uirec'u pi�rr»i��n cnn�roua[,u![rr,inr/rrimr,de�voli.�b,
___ '._ __._ _"" . . ur rr/ruir�u:1'eh��eotarr�Priur lu i!s i�ueaner,nho rvyuir�•.�
�he eeppli�nnt/nr eurlr prr ni(to/i!r u ai,�ned arutrrnrxt
_ --_'___'- '__'__ '__ -- thut hr i�li<ou�ed)a�.vennt tu�bv pruviciam n/!hr Crni-
' h�na tor b l.ircaae Lurr((:hapter 1//conevevnnng.ui(l�.Sa�-
_'_—____ __. ______"' . �iou?000/u/ll�rieron 3 u�(Lr I)u.�irio�s nnd Pru�ra.�iuuc
' - Cudr/orlhnlhricix¢an�rJllrorrjrnnr�uodtlu�hucic�nEhr
._� "- allr,�ad r�-v++(rlinn.Auv+•iolneinn n/,Sr�otiuu 7(13l.>1.�•
Required Date Ratoived uny��ppli�an�/nrn pvr�uic�e�Gjc���c Ehc upplii�nnt�u n iivi!
ApP�ovols Yes No or Approved - -'--- '--- -- -- prr�elev�+f nut neorn 1Lnn laru hurulrrd Jo/lur�/Si00/./:
. . � I I,as owne�ol Ihn piopwty.or my c•mploycu��vnih
Wuler Ccrhficarc - - +ugm ai thcii sola�ompens�tiori,will do i4:e•.vork,nnd
Ihr,structure is nol intendcJ or ofle•red for snlr.(Sr.i.7044)
Hcolfh Deporlmanl . �^ —,�-- �" — /3rnino.�.�nvu!1'ru/e.�.�duiu C:ndr:7'hc(:nntracfor'.c/.���onav
l.u�r dnr�u��f a�iJili'(u ttn ouora•o�pru���n[y«�Ln beeilds
fve De!>nnmrm " '- _- nr inr/rrnra�thrrrou.�mJ erl.ru dnes�uoG irurk.hinnv!(
� alrrnuAlr hi� mim a���/�loY�'�'b lruridad J�rtt .eiicli ,
Graduiy -'- '_ -" -"'___'_ prnornicnh nro uut i»(rndnd ur nJJoruJ�ir .�n/r. �
� humerrr,ahe I r�i(dinA vr imprnnrrrre��(i.�.�o1J vi(lrin nnv
(iooloyical "'_' -_ - � -_ -- " }�rnr of��orn�drliuu, Ihr ou�nor-hudJcr ini!!barr thr
h.n�Jrn u�prurinh th�eE Ar eleJ nu�lrruld or iinprnvr Ji»'
--"' - -'- . ._ —�. cbr purpo�r n/au!<:/.
Pedesinan Proteclion
(Te:nre.1(Conopy) I � I,os ov+ner ril Ihr propr.rly,om czdus�vcly wn�rn�
- ----- -- uny wi:h licen<rd�niitrariurs to coni�ruct ihe prulec��Se�
Speual In>peebon ""- _ 704A1 f3vunv�r mul Prn/euiunc(:ude: 77rr Cnun•n�[m't
(Conc 1�Maeon�y)IWrsldir.r{) l,iirn.�e I,avuJor�aot«p�lr In m�nwurrn//nu/�rrh•u�hu
h�nlds or ixeprnrr.�Hrrrvuu,�urd u�hn iuntrn��c/or a�cA
lot Urriirnqf? __ _- _"_ — ./�rv�j�-cf4 11•iElr�i �r�ubYtiltlt�(�J li(��n�iv/�iiersru!)17 11) 1lit�
C:ru�tr�«Inr's/.irrmr Lu�oJ.
Prn kinq � � ��m ezempt undcr Scc .B 8P C for ihis
' '"'_'- renson_ _
_-_'_'_ ...___ -
. .._— '_____'—_'___ Dute:_� _.._ _ wn� .__
Approvals Date InspacTor's Signalu�e fW INSPECTOR'S NOTES
locahon — _-'_'— ��r _"'_"_- ..__ ' f .
lSr.tUnck&Yardsl t��,�yN��• ��`-- ` (
—'-_' - �-._'- -
1 oundral�ons � �
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Frurne �
Energy Insu�atinn 'p V '"""'"' --""' _"_"_' '_' _-- '_
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I al h/Urywral I
Inferior -ZZ ._..._�._._.__�
foth .Cxleno .`-- - / ---' --- -------- - ..' � --
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Hvusn.Numbcr
C.orreri 8�osted �� '-_— -
Final
Entcr an{ronl ___ _
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