HomeMy WebLinkAbout0060A 0061AWORKERS COMPENSATION DECLARATION:_.. _ -._.-
jl jl1herebyaffirmthatfhaveacertificateofconsenttoself 4pPLiCATi4 QR -BUILDING PERMITinsure, or a certificate of WorkersCompensation Insurance, -
or a certifiedcopythereof (Sec: 3800, Lab. C.) - - - - "—'--- - -
IL[^1P28386( rnpany ?-elTrzn's. *>cl -. - -
COUNTY OF LOS ANGELES - BUILDIN.G AND SAFETY
PoitcyNo
D - Certified copy is hereby furnished. FOR APPLICANT TO fILL IN BUILDING
ADDRESS 951 Lob Glass Drive
Certified copy is filed with the rnumy building insper - [
SIZE
DTNG_-- - - - - _. - `' -- - - - - -- -- -
lion deportment:' - - - RESS _
Dote 2 22/85Applicam THE•ANUN GROLP DiaWnd Bar ZIP 91765 LocALrn DiamatYl Bar
CERTIFICATE OF EXEMPTION FROM 'WORKERS",... - .._ ._.,..._... -NO: OF SLUGS: AAAA ...__... NEAREST-
COMPENSATION INSURANCE Of LOT NOW ON LOT CROSS ST. G10L7d
This section need not be completed if the permit. is for one T :35581- ' -- -- --- -- LOT -
AccFccna -- -
hundred dollars ($100) or. less-) - - BLOCK LOT N0--82--_' MAPBOOK PAGE PARCEL -
TE .
USE ZONE FN AP. 1 certify that in -the performance of the work for -which -this ER' t9541--
permit is issued, I shall not employ any person in any monner- .- -
soas to become. subject to the Workers'Compensation Lows. - ESS P.O. -BOX-3329 - - - - -- - ---- -- Vf70ONDITIONS Q
Owiria.._ .. . ZIP 91722 .. _ INDale .' Applicant .. ARCHITECT OR
DaveS- 495-4073._: t15IRiC1 Roue IYPE.. _---- ... _FIRE. _. _PROCESSED BY 0llyCfTOAPPLICANT.' If, after making' this Certificate of NEER
r Impion,' you should become; subject to Ae_Workers CONST • ZONE
Compensation provisions of the Labor Code, you must forth- RESS 314 N. First Arcadia _ (CJ__,.. 3 y—`N - ,17 - d
with compty with. such provisions or, this permit shall be - - - - ---._, - —.._. AAAA_- _ _ . - -_ - - . y
deemed revoked. TEL STATISTICAL CLASSIFICATION APT. CONDO ZTRACTOR .
LICENSED CONTRACTORS DECLARATION - -_ - - .._ __... _ __._.___ _ ___ UC. _ _ LASS NO. d DWELL UNITS
I hereby affirm that 1 am licensed uncia, provisions of Chapter 4 ESS as ct170ve NO. 371580
commencing with Section 7000) of Division 3 of the Business and _... _ _ _ -. SEWER MAP
Professions Cale.' and my license is in full. force and effect. CITY _ CLA55 - - - - VALIDATION
FT. _INC. OF _ NO OF CHECK -
License Number 371580 lit. Class B - 2375 StoRiES -2- FAMILIES 1 -- ONE
VALUATION AAAA -
Controctar`i'M+' ANDE GROUPDate - 2%22/$5- -- - DESCRIPTION OF WORK NEA'-
S _ ADD
I am exempt under Sec. single l -
ALTER ® z0 0 6 Q E
B.BP.C. for this reason REPAIR _ $ _-' - 4 • • • • 21
Date: USE ItJG BLDG... DEMOL
Signafi,re APPLICANT TEL. FINAL
1 -329,34
OWNER -BUILDER DECLARATION _-. PRINT rim ANDM GMUP No. -
t-heiebyefficm-Chat Lam exempt fr4rnWa contractor`.sitcense - _. ..
AAA A_ - .. MxfS T" -Gv 7J • • 2 9.. 77 4! t=,'
Law for the following reason (Section 7031 5, Business and ADDRESS as abDm FIN " SProfessionsCode). - --... ._. ._...__.._.._ _..._ Qa'Z2.`55
PRkStNIBUILDING
1, as owner of the property, or my employees with _ gpDRE55 ___.-_... __. _- _ 006,1
wages as their sole compensation, will do the workond — ---
the structure is not intended or offered for sale (Section LOCALITY - C 3 - g • • •' a i• 1 '
7044; Business and ProfessionsCode). AAAA_._ - MOVING
I, as owner of the properly, am exclusively contracting CONTRACTOR NO. /O r -D ) • 5 (!, 3 4
with licensed contractors to construct the project (Sec- -
ADDRESS - - - tion 7044, Business and Professions Code). G • . 5 6 LL
CCTNSTRere is a constructionlendinga __ __ -
SET BACK,._. YARD-` :HWY.- TO7AL BAOC - - -
WIDTH.. . - -_ - S22-85___ --_ -_- I hereby affirm that there is o construction lending agency for ___FRONT
1he-perfortrtonce of the work-forwhich this -permwis-issued ._____ __RL—______._._.
Sec- 3047, Civ. C.). SIDE
Lender's Name Qmt'3.mnta]. I1limis
P.L. -
y
LDMA Ref. N - -
AAAA . .
gLLCaCjar P.t. fee.?'_.._ , . -Permit Fee - - Lendera.4ddress 231-S; IaSlle"
6069
L that e-cead ibis rcatian and.state that -thencert'y .appy -_ _ __.__.._. _..._ ._,.. ivwnce Fee- _LDMA P/C- M
m above info, do is ect. 1 agree to comply with all County Investiganon Fee -
g _ordinanc .an to w.s..rela-tting-to-building construction, iotat -.S _ _ - u and her . _._.._.. ...._._.,_.._.... _ --_.. LOMA Perm. N
y or re esentatives of this County to enter
upon t e o e- ti ed properly for inspectio u ses A -
a - SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigrata Applicant orAgent
W
O
z
0
UAN
Z
O
CCT0 ( O y m„ O.r tl0
m `ti Vy NY.i.»O
m
C w +•Sv:.O.i`i, O.y y N;u-4
m
Y
W Q''
y 'y r T Fr _ O
x Ou 6N ydCw +si
Y y
yy O o d •a
d
L' !C K
C
ism
3 V r ”" Y^Q O i1^i1O
U C CC O Y
N ~
O H O'tl. ,-Q mT!
O. O V. O''•
j '
I! ' m
O..N. •y N
O O N ^':O ;
d
N
a'm0.. " b it 1 tp, Y 41 O O a.t
p
L' 4d Y u 'd l •rJ .w x tl OWE a ^' A., w N N S \ A, d M «
0. a ' 'a
y0,-0,
G.
Q }y' '~° 3 - h ,': q m. ,
O u
f N O .. 'r O O u y m 4 .q m i. O Q L`3 C 'y V
d N
m e 'i a 9. d d
YtlOO
d m h»
y
b C y m 3^ x m • o
L m y 0. y tl ' x Zt Oi .' x m
J
tl .YO"m
4-5: .
3 "' O d 3. m
tm. Q w y •,, x m 0. .Li i. O m .`Z .ti
rn Q v '.. -p
C O •,, x 4 Oy O
W
O
z
0
UAN
Z