Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1028A 4311A 4312A
, ,. , ... _ ... ..... . . . . .. . . . . .� . .. . . .:.. . . : . . : ., .., . . ... . . . � . . ... .._:;:.. - - "� WORKIiR5'C041PL•NSATIONDf'CLARATION.� ' 76Afi4,T� :: � `� � �:. APPLICATION��FO �GRADIIdG PERMIT�� � ��� �� � � CE8071REV.2-BO) � � ! 'I hereby affirm thot•I�hsve a�certifica�e.of consent to�self . � � �. . � . � .� �. �� � � � insure,or a certifcate ol N'orkers'Compensation Insurance;or' � .. � � � "�. �. ', � ' . � ' . . . ' .. . . '' : . " a certi�ed eopy thereot(See.3800,Lab.C.) • '. COUNTY OF l05 ANGELES . . BUILOING AND SAFETY� , � ` 'NoIIcY y�. � Company .. . . . ' .. Q Certiiied copy is hereby furnished. ' ' � FOR APPLICANT TO FILL IN . SITe' - -'^j �L ;`�-- .���.���f ADDRESS �i'G / v�,.Ea'• � CeitlfiedcopyisfiledK�iththecountybuildingirispectfon � SITE • ��.(; j•�" ��;,�G��}y�:; � � . � � • �•� J� � � �,/ . , q 9•. �' L- LOCALITY f.l�f.h.�.,./�,bf �� ,•9!.J . deportment. . . . . . . . , . ♦ , . LOT f Datt Applicant � NUMOERS ..�U . . . ,BLOCK. � . � N�ARESTfiEET •C�?=.��d'"�J �� �f��a.��,.� . � CIiRTIFICr�TLOf EXF,M1IPTION PROA1\VqRKERS' -� TRACT" '-��,',-%w'�.,;"=r ; ' � � � � ' � DISTRICTNO. MAP NO. STATE FIWY. PROCESSEO OY :� W}IYENSATION INSURAIiCE ., NUMOER '. - � :' . �/..� Ja'ij yE O � (This section nced not 6e campleted iLthc w�ork involveS : owNeR ��'`-�SIUi�� . �.-1' ���•�•�,c � CUBICVDS. U MANDLED: by Ihc permil.is for one hundred dnilars (5100)or 1P55.) MAIL ;���,,J: `. }i`..1``�?[�'`` , .; _ j.�� � �� , . . ,. �kL ' �' �� ����� J 1 cerlify thsD in the performance of the wnrk fnr which this S CITY I;1 r::i)�:����i�� h,)�ei NO�� = =�`'"��y`J � LL ermit is issued,I sf�all nnt em I� an ersoryin an manne� USE ZONE SPECIAL . C p Y Y P Y •' --^,�._ � STATE � � -� � � CONDITIONS ' � � . •}�� � so as to Irecnme su6ject ffthe\4'orkers�Com�j+ensatinn La�rs. . ENGINEER ��•� � �ie:�Er ' REG.NO.� � , , �--,�-. � � • . �, , . .. Uetc�. _ . ��Applicanlf—'ti�/'�•�f'l"a--�." , MAIL '7�IC�..'�. I7i�Cl"L ' Lv NOTICIi TO ACPLICAYT:If,atlei making this CertlCc�te of �� TE��� ��c _� ,,,,n � � ' � . a. �. CITY: 7 :`C�+. � NO.� � ���.ayV �� Sxemption.�ymi shnulJ'fieca"mr subject ro'the �5'nrkers' � � � C<impensation Dmviaion5 of Ihe LaMor Code,ynu must fnrlh- ' GRADIR GT � ��ti�� _ � SEL: � ����y_�(� •F1NAL � � DY� � � � . • _ W' . �vith comply with such provisloro or'this permit shall be ' / 1 wU� r 'qATE , . .F, �dermedrevnked. �� � • � �• ' . qDDRES5�.7"�(%I'��IV: C-�I/k'(�f.-LL '� .lJj7� . . .. � � ucENS�u coNr2,�croRs nF.CLARATiont pROPOSED USE OF GRADED SfTE(SI v � VALIOATION'• � 1 herefiy affirm thut 1 am licenxed under pmvisionsnf Chepter � R��� 1'�j�;,+Z-�C•) � . ) .. �. � . . . .. . . . .�.' �+� 9(cnmmencing with Seclion 7000)of Division 7 of ihe fiusb t� _ � � , ' � ness and Professions CoJe,and my license is In�full fnrce anJ � ' � � ' ' � � ' � i ' � � ' � �• � . � • ' � etfect. .. . ..n ���/L/ . . . . / � ;. ,; . .... . . . .. . . . � . . ."' - r �.' ' � .. _ License Number"'S�� � Lic.Class � �/�� � ' � ' � ' . � � � �+I� . . � . � s:�.�.:.:..�'r • � %7/!�:fl���,.s /.��� �7 I���, CHECKIFSUPEHVISEDGRA�ING " . • . . . . . � �',:���'if'�'.'.' , Cnniractor � � Date ATUfiE . ` � ... � . . ' " . . , �I±.�}'rl�.�l•'••� �. . � � ':. , . �� /� .. - .;.,.. , , . . � OFAPPLICANT :�:�.......�5:... Yr� Y�.u.,a' . . � JS���r.,.�,���i..:.,�.. . �I�am exempt fmm the�icensing requirements as 1 am a' . Y. . TEL. �. ' ,� � . � .. ...�. � '' � nn �� �� �. Iicensed architect oi�a�registercd professional engineer.� " �ppAESS�1C:�' S��C'��.Ll'.NO•` :i'fu�tr.}7:J ' �� � � � �� � ,�I°�.�:�`�:u�I G•��� �� acting in mY professional.tapatitY(Sectinn�7051:'IiuS-: �� ' � . . . . . . .- . , • .. . , .. �...... � iness and 1'mfession4 Code).� i SURETY 5 /�. ''"-� , FlOND r�ry f�� 1 � _ p Y ... . .. . . . dOND � NO. 1 .. .. . . ��.��.�:C'QOOLi� +� . �..' .. . . .. • .. . .. i , . .� I.ia or Re Nn:..... ...............: . Date -.. . � � ...�... SUf�eTv.. .�. . ....._ ..r,-.-. � /,,r.' _ .- —._- -._... ....._ .._ _._ .',:�Yt''S"..:.:.�..'.:..�.._. � � g'' � - COMPANY .,'...�...... .. .cf..- .✓..�:l��LSY:�' .. , , . .. . , . �1; , . �..... .,��4:��:� r' � IIOAIE OR'NLR•RUII.DGR DI?CLARATION - . ` �I�ED•��.�/L OYC D � ��+•:a'''� � � �� . .. . � . :;�,v,L.�./�.�, �„ . . � . . . � • . �f�«.iE.,r�..o . 1 hereby:affirm that I am exem0� from�lhe Contractnr's; CASH ' �, REC'D . , � � �ATE . . . ' � !.,..„.,;,�.7.�.� . License Law fnr the following reason(Section 7031.5,Dus4� OENOSITS� � ffV _ � � , FILE� � � � � � � _ � , ���• � ' _ ness and Protess�on's Code): ` THIS IS A LIMITED TIME PERMIT� '�'��ra 9�Q Q � ' � 1. as�owner nt the.�ru�ertY: ��r my employees with': . .. . ' . � � . � � � . . � �'•s^;C. f�� � waga as lheir�<o1e Compensaliun, will.do.the work, . . - �A�L WORK AVTHOfi1ZED MUST 9E COMPLETE�BY '� '� � ' '�'� � ' � '�`� � ��(��� ••��^��y�'��' '• , 'and.the strurture is not intended or offered for xnle . � � - � . . , , (Section 7044,Uusiness and I'rnfessions Code). • - • � � • -' ' � �-� � 1 � � . . . . .. ,, . .. . TIME LIMIT: . .. .• .I�Q.,1�,��,=�"[..:,. . .. 1,as o�vner.of Ihe property.am exclusively contracting. � ' � � � " " ' ' • n•ilh IlcenseJ contrnctnrs �n tonstn�tt fhe ptojeCt• .EXTENDED TO: ��� �� .�. � �[iY: � .. � �'�'� � � � r Cy � :...'(Section7044,pusinexsandProtessionsCode)....... ...._'....... � ' • � �. ..._.. . . , ... . • .�,. �.� ,, , __. .. .......- -- -- .. . ....:•, �l��k'•.E- � ' �'CONSTI2UCTION LIiNDING ACLNCY.. -... . , . . . . � � . . --.... , � 1•� �� � ��} - �1 hefeby atfirm that Ihrre is a construclion lending�agency EXTENOEDTO: BY: • , � . • ��• • •�� • .�.��...��.���'. ;tor'the perfmmance nf Ihe aork for +a•hich this permit.is' // .� ��{�,f � � � ' � . �' ' � . issurJ'(Sec.3097:Civ.C.). . . P.C.Fee S I/Q`. �ti-:/, Permit Fee�.,� �.n�� ' - . ..., . . . ' ' ,�j,�:�.�'�5 Q .� i . .. •:Lender's Name � � � � � � ' � .. ' v.. . . � ' • ......:.. t:a�� . Issuante Fee.. :.���..��� _ . ... _,. ... .... . i�'J�' �� , . �•Lrndri's�Addrexs'.' . _. ... .. .. ...�......_..,...� . . . , .. :.. ..r- � � . ,f.u5� - �•....: . 1 certi(y that 1 havr re:iJ'this appllcation�and stote that the� ' � Total Fee. ��+1�=r'L' � � � • �� � '�r"""' ' ��above in(ormution is cnrrect.1 agree to tomply with�JI C��unty � . . . . /. .�I n,�i:���2. .- `-orJinanCes und..State laa�s relating to building mnstmcllnn. ,. � .r . . . � '. . . . � � . . . ' ' _ . . � . : - .. . . . .. � ;on errby nuthndze represent+tives of this County to entcr � ' � � � ' � . � � � . . . on ihe abhve-menti ed property fnr inspeclton�urposec�r � Sl?li RlVCR56 FOR EXPLANATORY LANGUAGG � ; . � . . , � .✓ /�:�i ✓"� (.;�-�./.) �%��'1' . • i ��Signatu�e�fGf crmit[ec� Uate. . . � , . � .. . . . . � � � . . , , • L/' ,.'. • . 1J . .. . . i , , . . . , . . ; , i __ .. . . - ' . . , \�