HomeMy WebLinkAbout1655A 1656A (9) , . . . . .._.. . _. . ._. . ..._. . . . _. _.. - . ._...,--- - - . . . .. .. ._. : q
.; �
' 1NORKERS'COMPENSATIONDECLltRATION ' . � ��'••'. ' � '.` '! � . •
I hr.reby o{�;;m,�a„�a�e o�e,,;�;��,�a<<o�=e�„o,e�F � - �� � �APPLICATION� FOR:BUILDING��PERMIT �-���;
insvre,or o crr�iFicaie of Vlorkeri Compr.nsation Insuroncc,
or a cr.r�ifir.d copy ihereof(Sec.3A00,La6.C.)� � � � � " ' � �
COUNTY OF LOS ANGELES BUILDING AND SAfETY
PolityNo�jj��ompc�lYf�l1S Tn3am.,;ry f'n, �
� Ceniiir.d copy is hereby furnishr.d. FOR APPLICANT TO FILL IN BUILD:NG �i f ni,2
noosEss �CJ ,
� Cerlificd co�y is filr.�1 wilh Ihr. oumy buildi nsp !!UitD!NG ( •
Iio deparlmenl: � nDo?E55 SC. IVeS Ct. �0�•
Do�e � pplicant ' ' CitY Dianon� Bar Z�p �p�q�ITY
� C TIFIC E OF E%EMPTION FROM W KERS' ' - " ' "' ' NO.OF�lDGS. NFAREST ... ... _ ...._... .__ _. _
� COMFENSA710N�NSURANCE � � S12E OF 10T NOYJ ON LOT CRO55 ST.
(This seclion need noi be compleir.d if the permi�is for onr, TRnR IlIOCK LOT . 14 �AP BOOK ' � � PAGE PARCEL�
hundred dollars(SI00�or less.� ..
zlif. Commtmities Inc'E� —3700 115E1CNE h+�P ���.. 3,�
I certify thal in ihn,performence oi Ihe work!or whith 1hi5 DWhFG� NO. ��� �. } I
permil is issved,I shall not r.mploy eny person in any manner ADC4ESS31H� A A1CW1 AVCilUC ��� , ���' S7ECIAL � � ��-�� �� � �� 6.
so as�o becomr.subject to�he Warkeri Compensa�ion Laws. O COnoiTiOvS � O
arr. Costa Piesa 92626 ._._ �+
, . . . . . ... ... ZIP . pC
Dofe ' ApPlicanl ARCHIiECTOR TE. O I
''�ICE TO APPIICANT: If, oftcr�moking Ihis Cerliiicolc of Aram IIasenian .o:siR�cr GROUP ttPE .. FIRE PROCESSEU BY . F
ENGINEER NO.
� ; ption, you should becomr, subjoct �o ihc Workers' " — 9 ,p CO� �ONE W
��mpenso�ion provisions of�hr.Lobo�Code,you musr fonh- p;Eu3�90 S•:esterl• Pl. i�1�0, ;;.B.92660 /d. '✓�''J � ... �J ..� . .a
wilh comply wilh such provisions or Ihis permil shall be � �V �n
deemed revoked. � . TE�� S1AiISTIfAI CLA 7FI[ATION APT. CONDp. Z .
CONTRACTCR NO. -�-.1
LICENSED CONTRACTORS DECLARATION . � � � � � � -�-� ���_ nn55 NO. D`xELL.UNrtS�L
1 here6y aliirm ihal l vm li�ensed under provisions of Chaprr.r 9 ADDRESS No393701
(commencing with Sea�on 7000)oI Division 3 of the 6ustn=ss nnd _ . . . . __ . _ _ . . ,.�i�_ . SEvv�R�1nP
Proiessions Codr.,ond my license is in fu�l force and efiecL C1n55 B 1 �� PC_ � �:�". " ' VALIDATION � �
5 . ,. NO.OF NO.OF CHECK .
license Number�,93z(�7 ` (iC•Closs � � STOR'ES FAMI�iES Oh'� � �� 6��j I�
� VALUATION . •
' �' ' CFSCRICTION CF Y/07K
NEW
�,�_ � " - s202,900.00
Coniracl � I Dale ADD � i:• e o •C�
I om exem t nder See. $.F.D. — P11n 4 p�7FR
❑ P � � � f •fiG0.70
0.8P.C. r his a5on REPAIR � S . . . ' ' � ' — '
USE OF
^:?GG.70_s .
Da!e: EXISTiNG OIDG. CEA!Ol ❑ ,
� Signoturr. APMICANi 1CL. FINAL C:C,C J r II�
OWNER�6UIt DE ARATION I�i!�1) NO.G6Z-3�0O . DATE-��� -���-� � �•�� - �� -
� t hereby oifirm that I am eae t lrom tho Controcbr's license �� � V�v' v�
low for Ihe following reaso [Scclion 7031.5,Business and ADDRE55 E�' 3 flV . C.Tt. 92E12�7 RNAL' • _
Profr.ssi6ns Codc): '"' ' � " �" " �� � �� YVCSEN7 SY �� �/ti:� � "
^ P.UiIDING ' . .
� I, as ownr.r of thr. properfy, or my r,mploye.�s with ADD4E55 :_� �.G F�!�
1 wag�s es iheir sol�ccmper.saicn,will do tho work and . '" .
' thc structure is no�intended or offcred ior sale(SeUion ����TY , � �+e.e • �
704E,6usiness and Professions Code). ' ' "� N.OVING � - . TEt. � � � � _, � � � � �
CONTRACTOR NO.
� 1,os awne�of Ihe proPPrly,am r.Mclusively con�racling . . . .:. . ' . . , '•� "�)L,O G
with licensed conlractors to conslruct the project(Sr.c- pDDRE55
tion 7044,6�siness and Professions CodeJ. ' ' �� • e�:i 2.[�i U u
� � CONSTRUCTION IENDING AGENCY " SEj�gA�� YARD HV/V TV�ApR�pfp�INEfRU.N �,yiU�H
I hereby affirm ihat�herr.is a construUion lending oqency for taONl G�.�G�—��i
the perform�nce of Ihr.work(or which Ihis pr.rmit is issued -� �� P.l. �� � - .
(Sec.3097,Civ.C.�. SiDE
. P.L ._ .. . ... . . .
Lender's Nome �[— (J .
. . . P.0 Fee 5 V OD�7� � � Pe.mu Frc� d I.� LD'M Ref.A . .
lender's Address p .y�- �( '
I tertify that I have read this applicotion and stare thol�he . . .F�t ,�c /J•�"y � issua�ce Fe� - �•� t�MA PiC M , � � � �
obov informolio ' . ct.I agree�o com�ly wilh nll County Invesiiga��on Fee p q .
or ino tes an Stale .Ia'' � ildin9 conshuctian. . . .. . . . . . To�vl Fex-" 'JSeC•� ' LD.UA Perm.q . . . � �
he by au h e rppr, ntotives of thi ounty lo enlcr ' � . �.
u t �v .�oned p opr.rty f�ms ctio purpnses. .. _. . . ._. ,/�A� .. ' . -'': :� . ' '.
� SEE REVERSE FOR E%PLANATORY�GAUAGE ��
�gno�ur ol A plican�or A9�n� �ie . . .. ....- . _ . .. . . . .. . . . � � . . . n�
� �
,. Z '�
' _ - o °
.., i .c "
�. G1 ' � o o n '.
N %t+� tC. O
p o 7 ^ n '= i0 1G � O ,r q O ' .
r f' U n p �". " O 'O �. b O .
T
.� fP O t�j C � ; '�? (1 C � � � C ,�c Q
Q O n � �+` n, o O � u O 9�' p o . � n ` w . '9
7? o o s s �'c � ° ;� '° ° ? 2 � � 3 I ' • Y
� •,,�^`�p � � �p -� 0 4't � �o ' 2
t�1 A1('� p � n� � �.c N � C � � j �
`-t C i� � Oo Z' N �p C 4, a . > p �
Z D
�, .�3 0 � �
� ��� o o� ° 1 o a ' p �o
� �� � � � � A � �
a; ',a' � �
"' D � f�
c ,q q
1� N � ,� o ° ' ' � �
: 1 �'� :. .!. o 'z y .a .�
�- .�, :� �� p + � o '� � '
; " 1 (1 v�� ` '
� �. G •v r, ' �.,
c� t �` �. �n , ..1 G
�� �r 4 � J , ^o �. �
�. � =� _ : ' . �D A b
�o ( � � F � : .
� ^� . '� � �
;-1 w s m o
r � o � 1 a.
� * ` M . ' 1 O'6
� N ,
� � .
7
i
C
O •
�
. : . . . z
N
. '9
. . . , �
. p
N
Z
. � O
' J
• N
s.
t �
. . � ' F ^ �
"� L �t'--n.�.�'C' i r''� � ' � �
. ' GSf .:'� ��� � e'�.` N „N � 6
�,o �,$ •`y c � � c e: � i N_ � �. « �.c C
�..�". �-L•� G ^. _ � 5'� fi � .:�. C' C "L 6 � � O !
j_ �i � .. t,,,�• �n f ...n�� C'...C ".� �[
`? .o '• .:. O — - 'i! -.. ...! � :7.
� � Q f; _ c' J�r'�c ��=.,� _r� � � � � � ~� � ���N���~ � a 3 r
0 U w M' �. t � �^. � � 'f �. � N 1 C'.
r p �y c � ��•' �n NN „ �c.,N�.� •.�? C� �� G _^ oC
' � 7 '�`N ~ T. � n O M;s ' `�' C .. �"�� 7 �' 7 ^ � ;,• ','�.�.^ F � � C �
C. C ,� .� �1 =
.. ' 7 'FF.�'� M ? � ,cr+"� �'� F �.��pO � �� �� 3� � �=' FN oaC
, • � ._y.' c''" N � � _• _ -� � c•._ � � . a ' ��°�� � n 3 ...
�� x :. �, ~ N C C-� ��a t" ' � _ � r � j- �'=�e e'� c' �i ,'t U �; i-�
, ' G' �^r, �n p � �'� � �3 f) �.", ��„"�.f " - i � '' $ �x'.' �
� 'O � � = ....� .� �y C ���tr� � ry�9 �=•�_^ �'^ n C � 7 ?
. _ '^i, � .. - . C`� `. ^ �Cl C.� p � C'� f .. ^y� (�'i
' t 7 �.r_ e,.tt. � C C N ��:� � +.0 '^ V
_ ' \ j� n`o ^"�3�:.(`� ry � _ � � �'� ��^ �m ��. C�•G^�`'`.=vi a V jp �„?
� �
L .",. �'��r:. O C t�K+' ��n .. : O p + » : M +`. ^n'� �. O p ..�
M - � � . . ,� r
��°+. �n `�< < c�. � �^ � c.. a.t �o-''� s.,�.,;�= - � o i. `�`% � 3 ►
.�i � �.o � a O � ` =} � y �'M�.� � f � ' � v.� 3. .:.H �.: � � •�
�' "' o c� _ •- �-„ na-=3 s..c.. "s..� V �r' . c „ •� p
O w:s..- (� c ^ c � c � ,� -s ., _ ,:
„ . „ � � N , ,� ._�..�.: o�. �.�. _.�= ' � ��. � � n 1
' . . � �� C..� C L�`:,` C"S O f��C r. C..� ' C..�.^, ' n O
. �.' 'y - � �' n ri Cr� � ~ �� 1 �. O �� i d 3 ...7:�„u C �,-•,Y 7
Q . �e�. ; ..:� � .. � C F-�." V ^ O G O �~" �v..� ~ � r.F � � �p O
T '�' ��+=CJ � ~ ::T�`^•^T^.. N N�[. � in� w.�,��^y'�� �'r .._C�.�+O
' . N ' O '� :�.C� (79 C.� � ::F C ti�+ F N C C y�Y � V h= n Z"�, �N
'�. ^ � -C ; � �C ^ N C h�'�I �C.- � � n
' � T� M^ � �' �. C^ � O O £ �.,{ia �
- n �,_.,: ' + � ' � �;...,=`�?.y�s._
. o �� _nQ ��.' , �
.. . . " 7. .. .':
� N V