HomeMy Public PortalAbout9552BISBY ST_Building (2) APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES ~ BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN B=M ADORES
I hereby affirm that I have a certfflcete of conaerd to Self tmue, 38 f�
or a certtfbate of Workers' Compensation Irmurance,or a certffled
copy thereof(Sea 3800,Lab.a)
Policy hic, Ccxrperry Lcx-, T
OF LOT Na OF BLDIG&NOW ON IAT. CI
❑ certfflad copy Is hereby rumlshed a NEAREST CROSS 9T
❑ Certtfled copy 18 f11ed with the county building Inspection pBLOCK LOT 4a *At)
deparftT-TLQ USE ZONE MAP NO.
Date Applicant A33E AMP PAOE PARCEL
SFECtAI.COfJDrfIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' TEL t4a
COMPENSATION INSURANCE- avi-n-m 1000 FT.OF SCHOOL? YES 40
ss
(This Section meed not be corrpWad If the permit b for one hundred ,e MTRY-7 6Rpup TYPE CONST. ME ZONE PROCESSED'BY
doltars ($100) or less.)
I certify that In the perfornwK)e of the work for whish dile permit Ile /� {V.� t
b Issued, I Shall not employ any person In mariner ao ks to41 / �v ` '-S
become -?I—
SU
ubJed to the Ci OR NEER TEL NO.
av sU4TSr1Gu RCATgN APT
Dete�—AppfJcant a-,as Na DWELL UNfT3
fvOPCE TO APPLr,4N .• H, after makJrng this CerttflcaGe of FEOURED TO-PL 8ETBACK FROM EXIST
Exertption, you Should become Subiecd to the Workers' TEL Na SET BACK
vuaD FIYrY PROP L!E Wnni
Compensation provWons of the Labor Code, you mint kxttnvftll FR10,N[f
comply with such prwblons or this permit shall be deemed revoked. ADDRESS LIC.+40. PL
LICENSED CONTRACTORS DECLARATIONSCECITY LIC,CLASS P L
I hereby affirm that I am Ilcer»ed underprovbbne of Chapter B
SEWER MAP
(commandng with SediorT 7000)of DM&m 3 of the Budneee and 3a FT. NO.OF STORES Na OfM
ns
FAGJES ,
ProfessioCode,and mn
y(bee IS In hill force and effect NEW El BK PO
Lbense Number Lb.Chas Y ADD A YALLvnoN
ContractorDate ALTER ❑ $ 7
❑ I am exempt (under Sec. REPAIR ❑ $ T
B.BP.C.for this reason DEMOL ❑ LOW F/C
-Dam USE OF EXIST1NO BLDCL URM- ❑ 1 ITEM
CJ FJ
co
. Signature ) TEL LDIAA Farm r 50 - 50
tl - c Z
❑ 4 as owner of the PmPatY or my enployeee with wegee ea O VITAL ti�
their sole compensation, will do the work and the structure Is ADDRESS [�, 5r0.5,0
not Intended or offered for Sale (Section 7044, Bush Dm and FINAL DAM .O�I
Profesabrb Code) w+_L TRE APPL".HT OR FmUFeSLALOM 0CCUFWT H4�E A HAZARDOUS wvERi�L t_� /� � C.t WGE
❑ I as owner d the property, em exduahety corTtrscthng with OR A MVTLit Corrowxa A HAZARDOUS 64UMI L EourL To oa c�vw tww THE /— �7
flceneed corTtradora r tory. am tine AMouN s ON THE HAZARDOUS Mit GLADE? FINAL BY
pro}ect (Section 704 , YES❑
Buelreee afnd Pn}fa6ElOrB C,Oda.) VLL THE�r^r}bio®+` use OF THE BLIOLM BY TRE APPUcwT OR FUTURE BUI-DM I O� 9/29/94
CCCLFvrr FL`OL111E A PE]:W FOROR MODlK=ON Faa1 THE 8CU7H
CONSTRUCTION LENDING AGENCY COAST AIR QTY W�6 T DftlWi eff PERIETTM C3-ECKLAST TO 7099 1 AMID:11
o ue.FS C�y�
I hereby affirm that there IS a cors&ruction Iard agency V Ree E] Nq.61 1
the perkxTnarae of the work for which this permit Is Iea»d(Sea
m I KwE FEAb -E FvzARooum.
e mxr -Le womAaTON GLIDE AmD THE azAac PEFYTTIq 1
3097,CW.C) THE
eoq caL i u�nauro wr F u►oETa THE Loe NQS
-ES cairn ok
Co
TmE 2 CFMPTEIT 220�tTKY18 27Q 1 W�iTf10UOFi 2, -0 C NCEFI"HAZARDOUS l'Ar •1 .r �(y
Lenders Narne WKEF1"REPORTM AND FOR CODUNM A PEFW FROM TH!SCAO►Q 3303 130.97
Lenders Address I TEI FJ
I certify that I have reed thh appfbation and safe wider penalty
$ of par)ury that the above Information IS correct.I agree to co" P.C.FEE �O PETW FEE TOT9- 13YO _97
R w" all county ordbTences and state lave rekekQ to buldng J`v • S 1 .97
�,�
�, �a�nd
Hereby authorfxe rapreaardattv�of ��C-0� rssuANCE FEE 2 C:-1L-1E�1C,�RY.S �y}qy IMESTIGAATION FEE TDTTL FEE T CMri .00
SEE REVERSE FOR EXPLANATORY LANQUAQE � AVO 0000-00101 9/x9/94