HomeMy Public PortalAbout5560 ROBINHOOD AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OE LOS ANGELES BUILDING AND SAFETY
h.
WORKER'S COMPENSATION DECLARATIONIC
FOR APPLICANT TO FILL IN BL�orx3
I hereoy'af`" that I hare a cerifloate d coneant to 9W lure, e1n n.ra ADDRESS ubd
or a oer-Wlcate c$V4orkDm'fompensatlon Irmirance,or a cerMad
copy thereof(Sec 3800,Lab.C.) CITY / �
/a v L.OGLffY
Policy No. Qxnparry WE OF LOT } NO.OF BLDGS NOW ON LOT
❑ Cert#led copy b hereby furnWied. NEAREST CAO88
❑ Cerdfled copy Is Mod with the county bidding Inepwdon TRACT / BLOCK LOT NO.
dopartnantV URE ZONE AMP NO.
Date Aapr� AssEssoR ANP Boots oaf" PAGE 61 PARCEL D!! SPECIAL CODMONs
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER
COMPENSATION INSURANCE T""" � �'3 wiTi-r� i000 FT.of scrtooL7 YES NO
(ThIs section need not be oonpleted If the permit Is for one hundred E, ADDRESS DOTFOCT GROUP TYPE CONST. FRE ZONE PROCESSED BY
dollars(SfM or lees.)
Crry Z 3
I aertlfy that in the perfarmaT,ae ar the work for wf,lai, this permit
Is beued I shell not empty any person hl manner so as t0 AACIiITECi OR ENGPJEEA TFl NO. c5rf -3
become mb)ec.�t to the Workers'
�,��/��/�.�.�Q BTATISTICJrL alssfxsDON APT cotDo
Date,,t46Aw APP x AL)DRESS CLASS Na- DWELL uNITs T
N07CF TO APPLC NT. If, efcar mak657 tftb to of PEOUFILD TO-UL SETBACK FFKW E)OST
Euaer VborL you a".d become &A*o t to the workers' CONTRACTOR TEL.NO. SET BACK VkRo HWY PROP LIE WIDTH
(',orrrpenaaifon provlsiorm of the Labor Code, Wu must *xth%tth FRiONT
comply with suoh provle m or thb permit ehaA be deemed revoked. ADDRESS UC.NO. p
LICENSED CONTRACTORS DECLARATION SDE
CTTY LIC.CLASS P L
I hereby affirm that I am Iloermed underprovbbSEWERrm of Chapter 0 SER MAP >-
(Commencing with Section 7000)of Division 3 of the Buetruess and SQ FT.S= NO.OF STORES NO.OF ES a.
NEW Q arc PG
Profeesiorm Code,and my➢cense b In ttAI forte and ettwt
L Icanee Number ur-Clean DESCfWTION OF YOM< t ADD !` �- 713T SrContractor Dete �+ ALTER ❑ " -ACCT.'
2L2�j !-' ` /Q�P1T( REPAIR ❑ 33 03 90.50 z
❑ I em exerrupt under Sec.
BAP.C.for thb reason DEMOL ❑ LDIAA P/C r /1
Date: USE OF EXtBTNO BLDG. URM ❑ ACCT.T
APPLICANT(PfWT) TI�JiO. LOW Perm r ` J r377.53
A1,as owner of the property, or my enployeee with wages as
thalir sole pompeneaYlort, win do the work and the sbi ctLre Is ADDRESS ITE1 J
not intended or offered for sale Section 70M, 11.mlr ee and �+AL DFa2
Profeealone COde.) ( wLL THe APPI1G,Nr OOffd�R TUE eF><orrxt OC«PMIr KWXE A HAZAFD«JD 6UTB AL -13--P-4� TOTAL �4 -U _ 1��
❑ I, as Owner d the property, am exokuelvely COrtt acdW with OR A A�rTLFE CCNI A I-NZAFaOIC W4EFY1 eOL L TO OR OFEATER THM n-E
(Section 7044,
Iceneed coniradare to oonstruot the pro}ect MIOLNTe ePECFED ON THE H1Z.AFlDOUe NA7EAWe Pf0F§ M GLItDEI FINAL BY F
vee❑ ruo❑
BuMxm and Profeeeiorre Code.) , CHAW1
WILL THE PfTQOrm«Ae'OF THE nl rr M EFY THE APPUGANT OR RnUW MALOM
VAOCONSTCTION LENDING AGENCY A"T w
A it (SaAI rt� eEE PS:* TT►r� eT
RU
I hereby afrfrm that two Is a oortetruciion lendirrQ agency for O.raWe
„�❑ ,�❑ G I—C 1 1 ihl9�r
w the pertormahce of the work for whbh We perm)t b Issued(Sea r r
3097,Cts.C) WIVElEC F,� '.M LINDE°HE F� _F21_r 1 F�'I 5:IJ7
�2-10 o? eiCCOMWW �
Lendeea Name WA EfKe EPORTM AP09 ONO A Po-v �T E 1
Larders AdoYeea
0 a.�OR,r4T
I aertfty that I have read this eppllcat n and state order penallyOf PC FEE ,{� PEFt/fT FEF �J
�co y oorthe dtrtwces bove �b he re to I� �,J(/110
and aL d"I:a representatives of thb County 1�3UANCE FFE
to er'dar the property for I pF.rpoees. SCJ
c 1JVE9TIG,TK)N FEE TCp1 FEE 27,
l7 '�
SEE REVERSE FOR EXPLANATORY LANGUAGE