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HomeMy WebLinkAbout1135A 1136A .. .. . . . ....... -� ---- __.....- - --- -_ __...----_._ . ._._. .._. _.__..._._.._ _ _ _...- -�-- ---______ WORKERS'COMPENSATION DECIARAT10N �"'^�� '�� ' ;:. •� , � ' '•��.�:���i `� �� .� insorebora{certitcmeofWokes'�Com1pensoionlnsura�e' � ��- ���� - �-�APPLICATIQN�-FOR�.BUILDING� PER�MIT��� ��; o�o certified copy rhereal(Sec.3800,tob:C.J; ' ' ` - ' � [OUNTY OF LOS ANGELES BUILDING AND SAFETY ' Pou�YNo.73WC005-2�9 0004 • Nationwide 35/A • �� Certified copy is hereby f�rnished. . ,. � ,/ FOR APPLICANT TO FILL IN BUILDING ' ADDRESS �I3S N. Feathen�od Drive � Certified topy ii filed with ihe covnty building in4pec- - ' gUILDING ; � �lian departmeM.`• . A�DRESS �]3$'rJ F' oa�e 6-19-86. aPP���o„r �ANDEN GROUP an DiainDTrl Bar -_ z�a 91765 �oca�m Diamorrl Bar � ��CERTIFICATE OF EXEMPTION FROM WORKERS' � � - - - �- -- - -• -- NO.OF BLo�S. � -� - t�nREST, � _ . --........_ _ -' ��COMPENSATION INSURANCE' � ��. SRE OF lOi . nIOW ON t0T CROSS ST.Hl ti Kr�oli &:Golderi�Spri ���s�� (This secrion�need�not be tomplered if ihe'permit is for one �-��-� ASSESSOR.,_. - �� � � � ��� .. .. .._ . _ . _. � . • ' PAGE�. FARCEL'.., � hundred dollars(5100)or less.) , , . , rR,,R- 35761 B1«K ior 23 muo eppic •' "' ` own�a �i-IE ANDIN GId�fJP No 967-9541 us� oNe �a �:Z 3�3 - � ._ I'�ertif that tn the er orem lo o�f^hee ork for which this �/_ . SVECinI--�- -� -�- � � ---- -- - -d Y P ' rsoninanymdnner ADDRESS�P.D.BOX-3329-� �- -- - �- -- -- � ' � permN is issued,I shall no� p y y p a so as lo become sub'ec1 to ihe Wo'rkers'Compensotion Laws. /U771 CONDITIONS ,v . ,. . .. � � .. .,:.�, . . ___. CITY CO�T71'k3 . - __.. _ - ZIP 917Z2 . _._ ____. ..... ..__. .. __.. _ . .._. ,- ;,0. �le'..�'' .:-• APPIi[ant ,' ARCHI7ECTO q. . . � . . TEL �� . . . � OTiCE TO APPtICANT: If,�oife�moking this Cerfificale af LdVC: S AIA 445-4073 o�sre�cr GROUP ONST! ' _FIRE PROCESSED BY_ .V emption;�you should become�sub�ect �o•the Workers' ENGiNFER �y NO. � Compensolibn provisions of the lobor Code;you�musf forth- qD�RE55 314�N. Fisst� Areadia 91006 - - I�.-- �3 .� �1 V - -�y wli h tomp l�.�wit h Suc h•provisians or f his permit s ho l l be --�- TEL. STATISTICALCLASSIFICATION APT. ON00: ' ' .Z deemed revoked.; � . ,a.,. , ; `iHE ANUEN GRiXJP .. , CONTRACTOR NO. '_" '.. . LICENSEDCONTRACTORSDECLARATION�. � �. - -- .- -� .- , �-- - ---��� - -- ClA55N0. -��-� ��WELL.LNITS � � � �� , LIC:- I hereby affirm that I om licensed�nder provisions of Chopier 9 ADokE55 F15 �-'7}JOVE No. 37158�� (commencing wiih Setlion 7000)of Division 3 of rhe Business and _ �iC B SEWER MAP , .-- � � � ' -� - � ----� . ions Code,ond my license is in full force and effect Cltt N+SS �- - ---- ----- 'VALIDATION- - � � .. . . ��. . �. � ��. - l�cens �71 580 ' .tic.Cltiss A ' SOEFT.1531 5 ORI�ES - MIL�IES �'_ _CHOEOC BK. � [e I I;7.J� Pro ess eNumber � � � � � . .. ... ..�. . � . . NEW. VALUATION-- -- �• 2-� '� � OESCRIMIONOF WORK �S1TK��.E�fe�iIll�Ly � '-' �� Cont�oct'o:: 'f4TF' AT11�FN GF2�i7R�ate ` 6=19-86 " r� ' s 56.560 . _� . ADD � ' ' ._�..o�L J 9..�..�.'_ �I am exem t under Sea � - a e 441-SF'—- - -- -- �� ,�; P _ .... . . . . . ALTER B.BP.C.forthis reoson � . . REPAIR.� . .S "---.. - ...! -.. . -� '-- -.'.•2 v�.�--9`=.'� _ _ .. ._ .._ _ -__ . _-Dafe:. _.. . - __ USE OF . DFMOI ❑ � �._"_ �.8.L.G�8 6 _. .' E%ISTING BLDG. '� $ignatUre �� . . � .._ .-� �� --- APPLICANT TEL. FINAL Q . � OWNER-BUILDERDECLARATION PRIM NO. _DATE-/Z���o'p��-�� � ---����-� �-�--�-�-��--�-�� -�� � ..1 hereby af(irm that 1 am ezempt from fhe Contractor's License � � � - ���y�7e � � � � � � � , . � 'aw for the following reaeon(Sectlon 7031.5,Business and /+DDRESS FINAL�� ��- ' ' '�'��' � . fesstons Code): - - PeeseNr BY '_' ' :=( � J:�J��, - ' -. BUIIDING � I, as owner of the properry, ar my employees with ADDRESS � � � wagcs os thair sole compensation,will do Ihe wo�k ond ` '� " � � � - � � ,- � ��- �- �t " • • � -- tha slructure is nof intended or offered for sole(Setlion ����TY � �-'� - ' ---- 7044.Bvsiness and Profess�ons Code).-- - -.-.._. ... . MOviNG . .- . . .. _ -� TEt. .. .--- � ,��--.- -. - -- -: . _... ..-----` I-�3 A�9,�5 D � , � I,os Owne�o11he property,am eztlusively to�lmtiing WMRACTOR NO. . ! __. ' , �Q 9 J Q� � -�with licensed mnrracron to consrrutt the project(Seo- - ._ ... . ...... ..._ .. _ .. _ ._.. ... ._.._. ._..-.- _-_ ___.._. . . - .e o. ADDRE55 ' ' ` � tion 7044,Bustness and Professions Code). � : � �5 p � i REQUIRED i0IAl5ETBACK fkOM I � _.� ' _�' O O..G 2"U 6 �"CONSTRUCTION IENDING AGENC'� -- - � SET BACK YARD HWV PROV.LWE WIDTH �� � �� � � � - �1 I hereby affirm that Ihere is a constroction lending agency for fRONT � ' � � ' ' ' � "� ' � tha per(ormance of the work for which�his permit is issued - ---- --P.�.�----._ _.... -_-.-- ._... .. .._. . ._ _. . ._.. .---'- -. ..._. _`._... ._...:... . _..-_ ._ . : (Sec.3097,Civ.C.). SiDE 1 �' '' � • � � _. " '__'_ ..._ . . .._ _ . __' _ ""__ P.L .. .' _ _" . ._ .. '.".__' _"".._ _ . Lender's Name �'A11t1L12T1'��. II.�.1TY�1S � ' P.a Fea a ... � 239.19 PEfT1�Fee. 339.00 IDMH Re(.q � --. . . _ --- . _ - -- , _.. lender'sAddress ����S_ _TaGallP� i �[f�„TT. � � ., • _I cerlify that I hova read Ihis applicolion and state ihot�C793_ . ...... . . . .......... Iss�nnce Fee-�� IO.50�- �� iDMA PiC M . �. . - ..� -�.� -�.��� .� �� � obove informalion' correct.I agrea fo tomply wilh oll County Invesligotion Fea � � ordinonces an te laws relating to building ton5lrottion, ._ ,._ .,._._ __ ___ Toiol Fee- 349.SO . ._._ �p�,.�,q perm.M���- � ' and hereby t ri e tepresentolives of this County to enter �� �� � � � � �� � �� � �� upon the e ned property for fnspec jqn urpa es. LDMA_- � � _ � . . � _ _ _ _ _ _ __ o� !/ �6 -. $75 - � -- $35_ - - ._._. . . _.. . p � SEEREVERSEFOREXPLANATORYIANGUAGE "-_'.-.Signamre af Applicont w Agen� . '' . Dme_' .. .'. -'. . ° ___. _. -_ -- . O � .� . . .�.. m T r r m T V1 T r 'L (/� T� _�i1 _.�. _ .._' _ " "" —.. . 7 O O � � � O O C N n Q � �� ��' O; O m�� Q i�_ _..i. ;.. 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