HomeMy WebLinkAbout1099A 1100A � � .
WORke..,, , .....fION f�
I hereby af(irm ihal I hovr�a««��;�aP�o��0�5��,�o,��F APPLICATION FOR BUILDING PERMIT '�
niure,��a cr.nificale oit•Jor4ers'Com ensation Insurancr.,
or a ccrn�ed c^py ihe�.bf(Sec.3800,Lob.C.�
Y �n�� ��p Y — COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic No��}�� an BU:IDiNG � C'1 � � \�h_ I�l
n Cerr�lied cop�;4 hereby Iurnished FOR APPLICANi TO FILL IN �S-
AD�2ESS c.�.
A1CertHied cepy is fited wii .he c u �b ii ng in eo- BURD'N � �
lion departmen�. ADCRE55
�a�e�Applic .1 CiTY Z�P J LOCAIITY \Q�Ct��'�j ��
CERTIFICATE OF EXE�l. O FRO � RK NO.OF BlDGS. NEAREST � �
COMPENSATION INSURANCE SIZE OF LOT NOW CN LOT � �RC55 ST.
�This s^t��en nead nol be complc�ed if ihe perm�l is for one "• a55ESSC?
h�ndred dollars(5100�or iess.) . TRaCTZ � BIOCK LOT NO. flAV @OOK PAGE PARCEI
,E�. �5E ZQN: �P to s 3 5
I cert�fy iha�in�hr.per(ormance oF ihe work fo�wh�ch ihis OwhF� No �� � }
prrmit is issur.d,I sholl nol employ any persC�in any menner � � �.` SPECIAL (y
so ns lo become subjecl lo thr.Worke�s'Compensalion laws. AODR.SS � � ��J CCNDITIONS I �Q 0
Dare Appliconr CITY IC L ZIP )i �
NOTICE TO APPLICANT: If, nfler making Ihis Cer�ificale of FNG N�FFRi C 7� N� .. Di51RiCf GROU� tt7E Fi4E F¢OCESSED ev O
Ecemption, you should beceme s�blect �o iho Workere' ro���`1 ,��� U
Compensaiion p�ovisions of ihe Labor Codr.,you musf lonh- �C^R�:S �' .v� �" �� W
wiih comply wiih such provisions or ihis permit shall be ` H � �� � - a
dr.emed rCVOked. CONTRACTOR � ,� STATISTICAL QA/SS�IiICATION ACi. CONDO. f/�
LICENSED CONTRACTORS DECLARATION �i� � CLAS$NO. v� DwEtt.UhiiS� � �
I hereby nffirm Ihot I om licensed undcr provisions of Choprcr 9 AD�RESS NO
(commendng wi!h$ec�ion 7000)of D�vision 3 of the 8usinessand �1 i�� SEWER MAP
Pre(essions Codn,nnd my license is in(ull force and effr.ct. CIN Q ,! � CLA aK � VALIDATION
r SO.FT `IfZ NO.CF NO.OF J CNECK
Litense Numbe � •� lic.Clnsf��J SiZE STCRiES FAMIIIfS OkE
� VAIUATION
Conhocl� ��Dale.�� OESCRI7TION OF WO,'K I:E1V S O O O
O�I� A�� �
��am e.acmpt under Se[. O Y �
AITER � :�� C'�.r'ii
B.BP.C.for�his reason � vEPniR ❑ s (+ .
USE Of � � � ���
Da�e: EXISTiNG°LDG. CE.M.Ct ❑ � .
$ignot�re �PRICANT TEL. FINAL(i /• � •�C;:.�'(�
OWNFR-�UILDFR DECIARATION ��iNT� No. DATE t l ��q e i.C:'"' ^�`:
I hereby offirm�hof I om erempl from Ihn Cantracfor's License '""'� "�
law for the lollowing reason(Seclion 7071.5, Business and ADC7ESS FINA����
Profnseions Code): a4eaE�:� 6Y / �r��'�� `
❑ 9VIlCING , ,
I, as ownPr of Iho properly, or my employees wilh AD�RE55 / ;_�� � j:i�,,.
wages as thrir snlr.compcnsation,will da ihe wrrk and �
the sMuciure is no�iniended cr offcred for saie(Seaion ����TY , I � �' o e � u . �
704<,Rvsinese end Professions Code). n'.Cv:NG 7Et. '
� CONTRA�TpQ Np.
I,os owner ef the propr.rty,am exclusively Conlracling � •2� ��;I?
with licensed conlranors to construct tha pro�ecl(Sec- ADDRE55 '
tion 70<4,Businees and Drofessions Code). • •G I :..��,'�-
CONSTRIICTION IENDING AGENCV SEt�BACK YARD HlW ���ApROa,Lin� WiDiH V
I he�eby alfirm fhat ihere is o cons�ructian lending agency for �2CryT . G F,�`.(_�:�U ti
Ihe performance of the work for which ihis permil is i�s�ed P.l.
(Sec.�097,Civ.C.). SiCE
P.L.
Lender's Name � '
/� tD'7A Ref.M
P.[.Fee S Permi�Fee �V
lender's Address I '
I rrily thm I hava reod this o im�io ond 51ate Iho1 1he � Nwonce Fee � � �D.X4 P/C M �
ove informotion is corret a .eo�o c mply wiih all Covnry inves•�povon Fee �
rdinarlF s and lafa I s fing fo ' ing co�slruC�ion, Tc�ol Fee ID.MA Perm.M O
and her by a oriz epr niarivee .is Counry�o en+er
Iu n� e m_tion praperty ' spr.ctlon purpases. �� � � ��•ao
, ��� � SEF REVERSE FOR E7f�LANATONY LANGVAGE
�9natu�e ol A licnn e�f Dc�n '
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