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HomeMy WebLinkAbout0859A 0489A 0490A (6) 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. 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