HomeMy Public PortalAbout9560BISBY ST_Building (6) WQRKF�S'C,*PYgSAT�N DECLARATION {
I he4y affirm that I howl a certificate of consent to self
Igwre, org9certificateofWorkers' Compenwflonln.urance, . . APPLICATION FOR BUILDING PERMIT
er
r a ctlflid copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES' BUILDING AND SAFETY I.
r Policy No. Company
Cbrtifled copy Is hereby fumished. FOR Af KIC4M TO ICL IN BUWING �' $,g
ADDRESS 1
Certffi�d Coppyy Is ft,lgd with the county,bullding Inspec- BUILDING ((��
flan depurtrhent. APORESS ,
pate _ Applicant CITY �. ` ZIP LOCALrrY
CERTIFICATE OF DtMFTION FkOM WORKERS' ' SMOF LOT x O. O►OF J� St �C V
:tOMPENSATION INSURANCE
(Thli;s*ctIon-need.not be'completed ff the permit It fop ons' - BLOCK LOT NO MSA RAGE
hundred dollars ($1 OD)or less.) TEL
t,� p
OWh ` ' .1` NO. USE Z0tE
i5a
I certffy that in the pefforrnce 6f the *otic for whlch this NO,
permit Is hyued, I ihalI not employ any Per 6 in any mannbr 1' a COND t
so as to beca'me sublectto tke Werk" CompinwtlonrLaws. ADDRESS i
Date . 'Appll�`ant . CITY G ZIP
Date �l F !Os•i
NOTICE TO A. CAff:'lf, after rnakIng thlk cote of. 'WCH nT-CTORDISTRICT LIP TYPE F 8Y. 0
fimPfloP, yov should become. wblect to the Workers BO
NWq
COtJSvc:m .flor
petr provlsrons of the labor Code;,yod'multt fprth ADDRESS O 1 . C
with corhply-with .such.provisions or this permit shell be'
deemed revoked. TEL�' STATISTKAL L
� APT:' [CONDO. -
CONTRACTOR NO. CLASS NO U- UNITS
uCi=NSEDcofJTRAc.'TOR$DEC�LARATroN UC.,
I_hereby affirm'ikwt 14tn licensed under provisions of Chapter 9 NO.
(obmn5end with$eallon 7000}'of DIYWw 3 of the Byalnesrand /�� uC. SEWER.AkAP
Mir I
Rofe�lons Code, and my license Is In full forcb and effect. GTY VI CLASS BK VALbA TION
Fr. CHECK
Llcenss Number uc.Class T_, STOQIFS F LES ONE ;
. . . W
Date VALUATION �V
Gon}roctor IPTIONEW N OF.WORK ;
ADD
ElI am exempt under Sec -
rAL
B.AP.C. for th Is teawrr L
Date;_ USE OF
DUSTING BLDG. ��
EX
Slgrgtbri OWNER� RA
UILDER DECLATION N7 I NO.S r`7� BOG ,r+
I hereby affirm that I am exempt from the Contractors UoensiA y51 d $ .G, l
Law for the following r:eosoa.(Sectlpn 7031.5,. Business and y
feMiont Code):
BU I WINO `
I, m owner of'the properly, or my employees with ADDRESS
'woges tra their sole comperoatlon,will di the work and _ �} 7OZ 79'Q b A-thetructureIs not Intended or offered for sale($ecilon.
7044, Business and Professions Code} MOVING TEL `, r�
I, as owner of the am excluslvi controctl NO.
with Ilcena*d con constrJcf the project (Sept i :a ' 9 fi 7 5
tron 7044, Business and ProfeWons Code).
CONSTRUCTION LENDING AGENCY YARD- ' PROP. LNE '_ �. ° 9 6.7 5Z
l here�y affirm that there is a conshvctlon leading o0erxy for
the p.¢ormance of the work for which this permit Is hued 0 9,25-8 7
(sec. 3097 Clv. C X SIDE
I P.L
kenders Nome
8 P.C. Fee Fee. LDMA Ref. I
Lenders Address' r
I'.cirttfy that I have read this application and state that the Issuance Fee- LDMA P/C 1
above information is correct. I agree to comply with all Coynty
Investigation Fee L
ordinances and Slate taws relating tq building conshuctlan, T0401 I" 'l7 LDMA Prm. �'
and hereby'authbri- i representativee of this County to enter "
upggthe entioned for Insp-dicin purp6se4• '
M taVWM PatDORANATORY LANQUA04
1A ,. Slgrteure cyfApp&anf1or Agent Date