HomeMy Public PortalAbout9549BISBY ST_Building (3) �WQRII� EIJ
ZS' COMPSAT]ON'DECLARIO
ATN L - '- ^ L r --=77-77
• _.__ ';" - _ _ ,. --- -
I h.4 affirm tfiat I have a c&rtlfioate, of oonsent to seff A P P LMAT I O rt FOR• BUILDING. P, E-RM I T
Insyre,-or.a Ificate of Work"'"Comperiscrftn Insurance,
ora COUNTY OFAIM ANGELES- ' . WILDING AND SAFETY-
- liry 1 FpnY
Certlflpd copy4ls hereby furnlshpd. .' AOR APPLICANT TO FILL IN Bum
Certtfl'ed copy Is filed W"the cojbty buIIdlnp tnspec. BUILDINGAA Y
flNfonpJlde�rrttm�ant. l� `+
;Dated-�-�._�APPllcant I r` I ZIP. / LCCALFrY
CERTJFiCATE'nF'DEEM 01l FIROM WORIdW",- ' 5iZE OF LOT - NOW ON LOT OF E
NEAREST_ t
COMPENSATION I W I ANCE doss ST.
(This 010
sedtort need.not be'coUnptetpd'K the pbrmlt is for•dne = TRAc `- Ilk- u6t -
buadred doIIat, 0)or aesc) PAS PARCEL
r
LIS
I certify that In-the.pec rrnance'of the::work fpr which,This O^`4R
permit is Issyed, 1 0Apll not employ anyipprson Jn arty rnp.nner •' - 1 fTl ,
so as•tobecome s.�{4Iact to the Workers`Corppensatlon LaWsr. _ /� - ` Q:
QTY.' Ci ZIP / U.
Date IlGaot, aRq�fTECT TEL. '.
NQTI�E TO APFN_CANF:,lf,%gfiter,makln{rithls certificate of t�R NO - U. BJP TYPE I FROC6S®BY, Q
�xeTupticm,; ydy,sbould .�&m rub ed,.1o. the ,Wgrkers' CONSr. ' ZONE
"OR
Compensation provlslgrts-qf.the igbof ,'ypu.tnyrf fort}}
1 t N
with tgmply wltfi aUah.F?gvlilpns or th.lr Perot[,shall be TEL _��I7g STATISTICAL CLASSI TION.,, - - _ Z
deerped rov¢ked. CONTRACTOR . j —
tIC�SEII.CX fT1Z44 .DE{3 ARATiON ... .: ' LFC
CLASS No. / rw I IJKfTS��
I�&m'by affirm that I am'licensed under proyblons of Chdipt�r'q. ADDRESS C �. 7�a
(commsndn9 wits.Sectiop 7000:of Drvislon 3,'of the.$uslnesr'
tJC StlHEit MAP
oldiSrofessrons and my Ilcert"Is In full fora•and C1�:55 J3K PG V]!�LIDA
SQ. FT.- /n
1JCett�tVu IG SIZE a/ TrOkES AMI ES f Of
—•`T�p VALUATION '
coptr«ror L j1 9 - PTI ON OF WOWC t�1N
I am exemo%under Sec' Uate XbDTER
B.BP.C:.{or this reason , /QJ 'REPAIR.� ;._
± EX15T]N( BLDG.
5•natu
b ra •owNER eulLDaR vEcl.nRAnoN: .
NO
��� _
I hereby affirmthatI om.exerno from the Contractor'sLltense - DATTp s
Lary fbr'the fol lQJvlhg 7e4sorj:(Sectlorj 7031.5,.BtAInejs Qnd v� L rY ` =' r�
p Professlons Code):
-- ?. 59.2-
1,
9.1 '
I, as owner of the m em to wlfh ; ADDRESS-.
DDR SS r...
. PrP PeiTY, of. Y� P Y� Ap0 •' - .
woQesas thelr sole compensatlorr,wIH d4 thew and _
the mucfute 4 not Intendpd`dr offered fgr'sale(Secilorl LOCALITY I f y � '� 25
`.70-04, I uL*nes�¢nd.Ptbfew1ons Code.)''' MOVING - � - 1 -
:� F, arownet of the,propefh,am ezcruslvelycgntracting tdo. f{` 59. 5
_ Li wl-If t_ rrC.
with'lrcenaid'conirpators iq cbnairud-J1ib project_(Seq- ' ADDRFS�
tion 7044.'5u;Irrea�.gnd PTofa"0t_tode.) Ij
TCTAI
�Iv'
CONST#UCT10N lENDJW AGCY YARD FrW - ,
I heriby, 91
affirm that them fis,.,a nstrvcHon lbrxJlnq opertty for. n .,
the performance of the' which Thi■ perT�tit Is-1 aued P.L ^T ca-cmI 2f _ S
(sec_ 3097, Clv: C:). SIDE r: : i�tt?,, 7
--P.L _ r.. -
Land e's-Nome
- -. .. P. 'Fee _ PsrmB Fes LDMA Rsf, * ;..
tender's Address
011
I certtfy that I'have read this applrcatlon prrd state that tAo-. issuance SQ
LDMA P/C t
above Information is correct_, I agree to tomply with all County' Investlyatlo�Fee LDAhA��
ordinances and State kiwi nlating'to building aohsttvctlon, Total Fee
and a ail of this Coynty to enter
g - SW!!HM=PM DKPL,AMAT99Y l Q1i¢uAdi
Slgrwture Applkdnt a Agent .. - .. .