HomeMy Public PortalAbout5552 ROBINHOOD AVE_Building__ Y �
APPLICATION FOR BUILDING
. GV , .` , PERMIT
CQUNTY OF LOS ANGELES . :; BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO F1LL d IN PLADDRESS
I hereby affirm Heat I hays a certlflcate of consent to seff kvkM BUtDNO ADDRE38 L�SZ� ROB/NN 2 N SIAIAlc�lp
or a cerUflcate of Workers' Compensation hTeurance,or a certffled
copy thereat(sec 3800,Lab.a.) QTY � �� zF TY 9�7 �� .
MiRM QTY, OA
Pdky CorTpany Wrz OF LOT NKA.OF BLDGa CNtOT'
ElCertffied copy IS hereby iu�mfehed. NEAREST CROSS ST.,
❑ Certtf6d copy Is fled with the county building hispedidT TAT / $ ' BLOCK LAT NO. ��
departmentUSE ZONE ALAP ND.
DateTT Appilcarit ASWANAP PAGE PARCr•1
27 SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' D4YNER (E
YES
COMPENSATION INSURANCECHINSU /�tllfd'—Zl�, Y?THN i000 FT.of scr-poL?
(ThIs section need'not be oompleted H the pwrriff Is for one hundred � � N ! 1rG T
dottare($100)or leas.) C}AOUP iYPE CONST. F73E Zt7NE PRO(E99ED BY '
V�
I certffy ttat'ln ft.performerioe of the work for which this pemnft CITY -TY Mms C1?Y � 4/ 76 d /%lA
IS laaued, I Mad not empty arty ier person In ar?y HWrso as tO AACNiffECT OR ENGINEER TE1 NO v `/
become subject tD the Workers'Compensation Lswe
OWN2;K RID SWT18TIC.&LQLV�/ '' �� APT CONDO
Dabs Applicant ADDRESS CLASS r4 V4ELL UNirs
NOTICE TD APPLACANf. tf, after making Hila Certfflcate of REQUIRED TO-Lk-8ETBAC,K FROM EJQ8T
Exemption, You Should become sub)&C- to- the Mckem' CONTRACTOR D TEL NO. SEI BACK )ARD }M1yy PFIDP LINE WIDTH
Censa
omption provisions of the Labor Code, you must forthwRh
cornpty wkh arch provWonp or this permit ehaiI be deemed revoked_ ADDRESS. LIC.N O.6k PL
FRONT
P L
LICENSED CONTRACTORS DECLARATION
CITY LIC.Ot-,r.9.9 P L
I hereby affirm that I am licensed underpfwFa 0nS of Chapter 8 MAP
(commendng wIth Section 7000)'of DMOicon 3 ot.ft Bbeirma and S¢FT,SZE P4a OF sTOFaiS NO.OF FA s NEW t7 etc PQ , r
Professions Code,and*ficeriee le In full force and effect }
Llaenee.Nurrber Lb.Chas DESC}�0PTiON OF WORK ADD 'WkUATKK+ 48
CorrtTactor bete AM A 84MRW4ALTER ❑ $ . 20, 42.E
❑ I am exempt under Sar REPAIR ❑
BARC.for this reason DEMOL ❑ LDMA P/C f
. Dam USE OF EX18l%R1 DO URM ❑
1 Si�afure APPL)C.ANTI(ffWM TEL NO. LDMA Perm
CZn
V, as owner Of Hie property, or Ry erTipic)eee with wages as Z ACCT.IF —
thW eoie comperleetion, MtI do.the work and the sbnj:hWre le ADDRESSC
riot Intended or offered for sale (Seorion 7044, Business and FKAL DATE '3303
.•J�1
Profambris Code.) Y&L THE APPUCINT OR am RE LADW OCCtF T wvnus.A FWA�OL rwa 5-Z4-1 5
❑ I, aA owner of the property, am exdLrsfv* contrsottrp wtth OR A LWIFE CCOCM04G A HAZARDOUS WVETML EQUAL TO on d£4EA�t1-yjl 11-E-
AMOUfrS 8PECF®ON THE HAZARDOUB MRER"FC-C(U4lON GUOE
kffKBDd Dorrtradore to coretrl the VnIect (Section 7044, MAL BY ' ACCT:T
Business and Prcfesabrie Code.) YES❑ NO❑ ^ J 4 1�
*1u, THE FC EN B DBC OF THE CCM BY THE APRJCAXT OR R MA E BLLDI • .i
OCpUWU REQUIRE A PER&9T FOR CCOt8TRUCT"CR►rCCd=rgF N FROM THE-8OUTH
CONSTRUCTION LENDING AGENCY �a°LwrrY iT DmTFvcT lecAaW BEE Po3"TT c>EpOiQT FOR j, 2 IMS.
I hereby affirm that there b a oxotu tion lending agency for . YF8❑ NO❑ yJ
CD the performarioe of the work for which;Hiss perm R b issued(sec I HWE READ 4E HAZARDOUS M4FFIAJJ3 wv at oL of AND THE Br1a�PEf1ITTN0 TUTF1� t 513Q97,CIV.C..) - l-Ep ff I lP4DER8 M W UNDER THE LOB Ak"B- 9 COWN CODE,
La
rder a Name
2.CHAFFER FER 2-Z0 SECTIONS 00 2.2a 140 CONCERNHG HAZARDOUS
C
M04FRALB RE3'C)Sm 3 AND FOR CBD�lM3 A FROM THE 9...1:a .LPIJ
LedlWa Ads
o
_ OAA
I Gs(Hfy Hint I Nae read this appJlcation and state Lader penalty
of perJUry Heat the above Information b correct.I agree to corrPIy Ra FEE �D �^0 PEFtMR FEE
fth
vall county ordirien and state laws relating to bueang • -�1 3/24/95
construction, and hereby auftrtr» fee�rlta this County taSUANCEFEE �•�� 4621 1 AM1-1*31,
m psc5on DurDbee&r 'M/EST03ATION FEF TOP,L PEE -1
SEE REVERSE FOR EXPLANATORY LANGUAGE