HomeMy WebLinkAbout0859A 0489A 0490A j � ''�..� ' ._, ._..._... �
� WORKERS'COMPENSATION�ECLARATION � �-� � �-- ����
� ,'raby affirm ihot 1 hove a nrHflcata of�o�sa�„o,a�f _,.APPLICAT���I� FO� BU�LDING PERMIT
:�nsure,or a esrtifimte of Workera'Compensation Insuronte, � .
or a certified copy thereof�SpeC.3800,La6.C.�
volKyko�S�'�84npony_ST741'e FH4J� COUNTY OF LOS ANGELESr. dUItDING AND SAFETY
Grtifisd copy 19 FIBfBbY IUIl115I1O�. BUIIAING n
❑ F R APPLICANT TO FILL IN ADDRE55 ? v C� �4.v[
r i led copy ie filed wlth the covnty buildin 'nspac- BuitDiNG � T�)
tion department` � AODRESS .7j�
Dafe'�Applicant ' [ITY Lv �p�p,��Ty CCa...�e� �- • >Cvl.
�r �(;�C4RTIFfCATE OF EXEMPTI N FROM W ERS' NO.OF BlDGS. NEAREST
COMPENSATION INSURAN SRE OF LOT NOW ON LOT D caoss sr. Ga1 " c
his s�crion need nof be eompleted if permit is for one �Att . a5 BLOCK LOT NO. y �ESSOR
hundred dollars(S1 W)or leas.) MAV BOOK PAGE PARCEL
��' �� USE ZONE
�certify�ha�In�he performonce of the work fa which this ��R �' �`� NO.
permil is iasued.I shall nW employ any persan in any manne� � SPK.IAt ` p � O
so as to become subject to the Worken'Compensatian Laws. AooREu ?' �� �-0 CONDR�ONS i�
Lp� U
Dare Applimnt CIiY � ZIP �V �
NOTICE�O APPLICANT: It, uNer moking�fhis Certificafe of �� � ��' �� DISTRICT GROUP ttPE FIRE OCESSEDBY O
Examptfon, you ehould beeeme aub�ect to the Worken' ` - �1.I �/ N�' �a �N$LV�f + V
CompemaMon p.ov�sions of the tobor Code,you mmt fonh- qpDRE55 . ��LrA.V � r/ � .�7j �r 1 W
wBh camply wi�h auch provl�lons or this�permit shall 6e _ . . -""� �� a�
deemed revoked. . �pNTRACTOR . T��� STATtS CAL CL455iF TION ADT. CONDO. �
LICENSED CONTRACTORS DECLARATION CLASS NO.�DWELL.UNITS � �
1 hereby nffirm lhot 1 om licemed under provisions of Chopter 9 AD�RESS ,- � p,
(commeneing with Seciion 7000J ot Division 3 of the Buainess and �� w � �� �i� �R� � � �
Rofesrsions Code,and my license is in full force and effecr. �y(y Ot/f M� .�? �ip55� ��'� VALIOATION ,.
p'�i'L7l � SQ.FT. NO.OF•. w- NO.DF• CHECK BK. PG.
�cenaeNumMer�^— �ic.Clas Si2E � SiOk�ES. v FnMiuES ONE
Conirattod"�L�-7�V�N ��,� -�� � NEW sALUATION
�"'--�,uale � �FSCRIFfION OF WpRK
� aoo � � �08`a9A
�I am exemp�under Sec. � AAER � � �• • • •2 3
B.BP.C.for thie reason REPAIR � _ ��� ?9q
Dcfe: E%STING BLDG. DEMOL ❑ � ! 1.1 0 C,3 3
SiyntlturG APPLICANi _` TEL. '((� �Al • �.1 i�i`.�J?
OWNER-BUILDER DECLARAiION ��NT B N � NO. pATE "�
I hereby affirm thaU am azempf from the ContmUor's Utenee �, vN /, � t� .10 �^ ` � �y�� �����$�
law for the followi�g rw�on�S�ction 7031.5,Buiiirose and ADDRE55 V i° FlNAL G L ^
Profeuione Cade): . . ...-...._. -. - - FR Nt 8Y �. • • .7�
OBUILOING .
i, ns owner of the properfy, or my employees with ADDRE55
wages as iheir sole compenaation,wiil do the work and � /� � • � ��n 4�
the ahucturo is nW infended or offered for aala(Setlion ��0`��TY t =
7011,Business ond Professions Code). h�OViNG TE�. �i
� . . � �;r�[':5�
� I,06 owner of rhe property,am excluaively controtliog CONTRACfOR NO. J,l\i - fl$�3—$8
with(i[snsed conhoc�ors to consirutl ihe projCtl(Seo- j�
�ion 7044,8vsinees and Profeuians Code). ADDREu +1 .
REQUIRFi� iOTAI SETBACK FR �11 � . s G 4 4,G i"i
CONSTRUCTION LENDING AGENCY �7 gq�K YARD HWY pROP.LINE WIDTH
I hereby aHirm�hat there is a construction lending agenry for FRONi �� • e w � �
the performoncn of the work for which this permi�ie ias�ed P.i. � �
(Sec.3097,Giv.C.I� S�DE .
P., 11.482G0
Lender's Nome fy �
� � l �O IOMA Ref.N �. • i.�f':[�i:i)c=.�
� Lender's Addrets P.C.Fea t • ie.mit Pee •
` C�'��Q � GflO�-8�
� I certify�hat I hove read this opplication and atate that the \�, iuuanro Fee d.� IDMA P/C N
above informafion is correct.1 agree to tomply with oll Co�nty 1nve�iigotion Fee '
8 ordinunte�ond Sfate laws relating to building conatruction, Total Pee IDMA Perm.N�
R and h by a�thoriza r prese�tatives of�his Cou�ty ro entar
m� upo o ra n ned property for i�spaction purpwes. L r /l,�� ��S Q';J -���M�-
� . .. .. ...... . .. . ., . .,. .
�3� SEE REVERSE FOR EXPLANATORY IANGUAGE��,� ,
Sign Applicont or Agenl Dofe
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