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HomeMy WebLinkAbout0943B 5918A . WO. ..,,. .„ . ..- .... .�.. - �...._.._�___ ......._ .... ... ,_..... . ........._.,,._.,..__._..,..._�... ......_.... _. _ ..., _ .._..., l I Fer�by off Rm Jhal IOM�PENSATION DE�cARATION � , .�.::' 3�'�.1`t . � . .�.' •".� � •.., ..�. . �.. , :. 33� . . ve a certifico�e of consent t . . � .. . .. „ __ __ _. . ... . . . . . .�� - ,.;. , o self - �OUNTY OF LOS ANGELES R;BViLDING PERMIT � � �•�sore,or a cerfifimle of Worker{Compensotion Insurance � ,;,�r a cer�ified copy thereof(Sec:3800;Lab.C.J'� � -��� �-� - � �� � � � _ APPLICATION FO O yNo.��o�2r�n�� ��. BUILDING AND SAFETY . ,.._ : ., i .. �. ' sunoiNc � D_ ' � Po it j Cer�ified copy�s hereby furNshed. FOR APPLICANT 70 FILL IN qppREu oCeZ,(o 0�,7, �i ' f4, ,�Ceriified'�opy is filed wi�h llie c na v'di �� �s o- " '� BURDiNG / � . O�� tion'deportmyent. ADDRE55 ����Z ��0�I� r���lA�(f y r7(j• i �,�� '. i , ' , . .•.., ,.. . �Dole/ ��"�� •�' �APPlicant ..- CITV ��iTrloNh���s�\ ZIP ' LOfALITY ' � i � ��CERTfFICATE�OFEXEMP NFROMWORKERS � �'� '-'.�'� -� �--"""�-'�' "�"---'--'���"` �'-NO.OFBLDGSr- � � �--�- � ' NEARESi----. � . . ,--.. .__ _.. _.--._.-_._____....__ ... . �� �•� �'�'LOMPENSATION INSURANCE' ���� , SiZe OF i07 Now oN ioT �aoSS sr. . � . ..� . .,, :.� �. . . (This'section�need nol be mmpteied if fhe permil is forone ---- . -_.____.___.._�._._"'_'._.-._...... ...._.'_'_.'._._.. _...., quE550R ., ,'- -� . . � � . , � . TRAR BLOGK l0T NO. � r RCEL I ermil ie isoed,Ihsholl nol em jo o�f^he e o�r hundred dollars(E700)or less.) ; r .�/ ' -`��- OWNEfi-`O�'I�M�I���'L-- ---Np�.t'J-132y f USEZONE ONDITIONS �� Y. P k for whlch.rhis . PA „ i T P � P Y Y P n in any monner �} � d C � .�.� /. /+� ... . .. _ .... ' I VA E so as lo become subjett to the Workers Compensotion Laws. �. aDDRE55- 1 D���� �'��'���-�������-i�����-, � SPECIAI� -;O NOTICE TO'APPUCAN P 9: -.,. _��. CrtY_..�..I���1 G•_..�'�G��'..�._.._Zia �� �_. ..... . . - . . - --._ . _..:,.. V . Ezemption,' ou should become�subject��to�the�Wo � Vi,�7 � 9�//f� a K Date �� A pLcaM ARGHRECTOR TEL. ^ , ��T� .� T: If after'mokm Ihii'CeAifimte of ���. L�y�„C�({'rpJ .DISiRI . _GROUP ttPE ..: . .. .FIRE__.. . PROCESSEDBY_. , I y rke�i � - ENGMEER NOr ZONE Compenso�ion provisions of�he�lobor�Code,you must forth• qDDRE55 030�L� 1i•l�'1� ���,� / / /✓ iT2 � ---� � ""'�' �.N with comply wilh�sVtb provizions or��fhis pe�mil Shall be ---�'-- -f �,�y�� TE �� STAISTIGLLCLASSIFICATION � i � APT. ONDO. '� Z dBemed reVOk2d:.�;� ,.. ,,..,�... ...� .... ., ..`,,...� CONTRAROR �J V����J NO. s�J/ .. LICENSEDCONTRACTORSDECIARATION . :�'�.•. -� ' ----�u.. .�i ... .. r, _._..__.I�C: . - .___ .. .. -_ . .... , . . . . _...._ ......_. �S CLASS NO. �WELL.UNITS I hereby affirm ihat I am licensed under provisions of Chop�er 9 � nDDRE55.-r wIz� � S ('C h10. , , , � g Y � t6e Bus'ness and _... _ _ .-: . ... -- , cHeCK., ' $EWER MAP � . . . _ . _.... .. ,. commenan witb Secfion 7000 of Divison 3 ofce and effed. CiT�' ~ �-'- - � VAUDATION--�� �, oiessions Coife,ond m��full for , 50.Fi...`Q Q NO.OF_ NO,OF�_ �� �� ' ' �� Li[en5e Num6er Ua Cladi' �� SIZE STORIES' FAMIltES ONE � � , � G..._- --- ------�- N�__Q VA►VAT� . �- —_'�. i� ' �. �. �...� _. . ____� : Conrrocio T4���,A�J�Dare.. ....� . .' oeseei`rclfnr RI�p�ZOY�f'.�+! _ . AOD � S , ,,; ❑1 om ex�t und��V tYn. 1�. . � '.._._." AlTER� � � ��, ,'_.. .__ . __• . .____. .._ -- gZ�i�tT,-�1. � . s.. ._ .. .._ _._. ,, ,_ . : , P . B.BP.C.for this reason _ _ . REPAiR. ..�.. .._ . . ... .._ �_. . :__. .._..._. . .. ......... . ...... � , Dal� EXIST�ING BLDG. d��IGy S DEMOI [p ' . ( ._._._.._ . �0 9 4.3 B _ -- _ s9oar�.e' . . .: arr�icaNr � Crab r� !., r�i. q^V, �I,}� FINAL , #�.. . .23 PRINT �O�F� � I�rJ NO. -3�'i"t( � �j` ��.. . O E 'BUILDER D N •�DATE� �--- - �� -�- - ' , -I hereby affirm al I am erempl f om tMe Conrrocto:s License n�� _G. �j}�j�»��.I 1, y i � . ,, � •r�5 9�rj� , � Law for the fo lowing'reaion�Settlon 7031.5,Basiness and ADDRESS "i ' \ �' G '��" FINAL�'� � . ___.__ .._._.__ �- - 'Profeisioni Code): . . .'. --' '-- - . R NT . By . .�.�.. . .. ►�-���5 9.5 0 u���� ❑ BUILDING �A.�� A-y ��'J�� � , ; I, as owner of the plo pert y, or my em plo yees wiih _ ___ ADDREu .._ . . . _ __ . � �-�wages as their sole compensation,will do the work ond . . � �- j� , �2� 9-a b the structure is not infended or offered fo�sale(Sedion ���ITY y� -�� � �_ � � . . ...7044.Bosiness�and Rofessions Code).�� � - �--� '�' ' MOVING--._ . .. .---N .. . -. -. .TEL: -- -.. . - .... .-.. _ _. _.._. . _ ..... .. CON7RACTOR u O{1 NO. I � � ' � I,os owner of Iha p�o per ry,om exclusively contractin g _ � .. .with�Iicensed�contresctors ro construU rhe Pro�ecr(Sec-. . ..�. - --..-----. -.._ ___.. __ _ ._..__. __. ___.. -- . --.. ....._ _ tion 7(1a4,Business and Proiess�ons Code�. aoDRe55 � �, .. . ....... -CONSTRLICiION IENDING�AGENCY '-'---- ...`... SE�BACK- vARD HWY. - TOIAPROP.A NEFROM-. WIOTH ....__ _ . .._._ .. ' .__' . _._.... _ _.��J 9��F��A.... ,� � I hereby affirm�hat�here is a mnslruUion lending agency for FRONT �r�� •���•�������' . --thaperformanceoftheworkforwhich��hispermitisissued ........ .P.L.._....... .....--" ---.. .__ . ..----__.. ---.._ .__...' . ._ ..._ . ___._�__._.�_-_-._.. ,' . -. ,- ._-'. . -- (Sec.3097,Gv.C.�. SIDE � • •fj(�5�Q '' � ..P.l....... _ .. . _._ ...__.."_. _. ..__.. __....'_ _....i .._._.. _ . ___.� .. . .._' '_ ' "_ ' '_" ' ' .. _. . ..._ _._ ._._". .... ... .. ..__._.. ._.._..._'_' lender s Name . � � • • •,8 Q.Jr Q,c�i�! lO• ��Qaf.M ._ � ._ . . . ._ ._. ... . .._._.. .._.. PC:�FeeE . -.�._ PermitFee" � .._ . __..... .. Lender's Address `a 5.� ' ��.� � 8 6 . I[ertify that I hava read 1hls applicati0n and sfafe ihat.iha _-_ .'_'._' _ ._ _"-"-._' bsuonce Fee- -......-.- -_..-- LDMA P/G 8 ..... _.._._._ ,... � .... . . � . �o6ove information is correcL�ogree to comply wirb all Counry i��esegor�on Fee ' �, .ordinonces nd Stata law elating to bullding conslroction. ._._.:- --_.-___..-___'__-.-. -- Tora�Fee- - �O�-D'-—` LDMA Perm.N �'--.-.-�-_. ...... .. . .. ... . . ----�� � :�-i and her au e� se ati es of this Coonty fo enter , , upo o - n i d ry f inspetlion purposes. - �� ' ... . . .. �J . . .__ . ..�__ . _., . . .._ __.__._ _ _ _.' _-. . . _ . X �^/(i� SEE REYFRSE FOR EXPUNATORY LAHGUAGE � - _- _ ,` ignoNre of App' nt or Agent' . .. ..... .Dote�- ..._ .'._ _........ ..... .. _.. _.._..._..___ _... __. . _ .. " .___.. ..... _.... . � '•..,1 . _ . . ' . . ......._.... � . ...... . . .. .. . . ' . . � Z a - o 0 ..�. _:n. .��- ;Q• ' ' _ N T��. •-f�9�' �p '�<p IO �(� �� i �' (1'O �.0. O' O.. '.� �5 ti O � � � n N p� � . 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