HomeMy Public PortalAbout5564 ROBINHOOD AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKEWS COMPENSATION DECLARATION POR APPLICANT TO FILL W BUILDM ADOREBB
I hereby.f11rtn that I hove a certtfloate of correrrt to eels InurBUIL.DM ADDRMP 41
e, b
or a certffloale of Workers'Conapersarion Insurance, erttf
or a cled 46 ,
Dopy thereof(Sec 3800.Lib.C) �T�lTi co w� UT'�-rE Mid1 E r 1 L°cWrr
P,o,f/�"r Ila /0 d y J S- 90 ,�ay i urs. a.Np s�of LOT Na of naw otv LOT
LO MrtHbd copy Is hereby fumbhed. S.
❑ CwMed copy Is ffled with the cou+rty tx>ildiig Inspection TRACT BLOCK LOT NO. USE ZONE Aloes Na
department.
Dab 4—/-f��kartt ABBI�BOR BOOK PAGE / - / 811IBMAL CONDITIONS
cEATmCATE OF EXEIV ION FROM WORKERS' OWTAERK 14 Y 40/— w,Tl-M,Doo FT of ecrloo T YES NO
COMPENSATION INSURANCE
AODR�B
(fNs seotiora need not be oonapbted H the perm It Is kx one hundred ,5' D Vw&,004 qU DreTRrcT .OROLJP FIRE ZONE PROCESBH1 BY
dotlrs(#700)or bsa.) L-
aP
I certify that In the perbmnr�of the work for which this permR ,( G' .4r -- /� 3
r Issued
I shall "employ any person In any manner so as to AACfiT2(T � 73
OR ENCIN � T _NO.
become KtYKA to the Workers'C,ornperxatlon UsIm ,V MAMMAL CLAMAPT CONDO
Deb Appllcard APDRE88 CLASS NO. DWELL mrm
MOT}CE TO AffUC4NT If, after making this CerdRcafe of REQUFI® TOTAL SETBACK FROM EXIST
Exemption, you should become subject to the Workers' ' // �'�' SETBACK YARD FfWY PROP Una= WIDTH
Compensation provisionsth
of the Labor Coda, you must forwith 57y-0365 FRorrr
oompty with such provislons or this permh shell be deemed Tevoked. ADOREBB ALCP L
_ Lr-CLASS
Al6!7 -7tyv DML. Sal 6S
Sim
I hereby 1 am licensed under proviskm of Chapter 9 TIION Cr f1 �C X 119 PL
(oommer�,p with Sec tiDp 7000)of DlvWon 3 of the Business nd 94 Fr eta of sTOREB na OF r WA��
Prohallors Coda.and license Is In full kxa and&lea / / NEW ❑ BK pa , e
License Number L1o.Class C-34 OF WKM ADD ❑ VALLAATIOMMe uF�,
Contreotor?L�a Cs C Date •4c ALTER El $
❑ I emaempt under Seo 10O / Ce,2 / REPAIR
m ❑
DEMOL ❑ LD"Pro r
Det« /y^ /_4 p USE OF DQSTINO BL DO 1 .uRm ❑
o,ry
❑ I, d owner of the propertX or my employees with wipes as 1 JTEMS
thetr sob oornpenaatlon,wUI do the work and the slruchlre Is T
notes ofesslom )Hened for sale (aecdon 7044, Bustneas and u I p • Qc o+ 9�o I ,,•,ALt�►T� T 105
wet THE APPLICANT ORF RIMO■ MOoc FAKTHANDLE APAZAFKXXXWUaF.AL I 1
owner
OR A 1OCnia4 COHDUNM A FLAZAFDOLM YR1•iAL 6QUAL TO OR GIFIE TFMN ■
❑ It, se od ooraof the
rs oo , a m its pro}eot..(Sectbn 7044, THE AYOLKM ePscsso ON THE FMZAIDOUe MAMMALS as 0F@&4n n GLlsxr P94AL my
yea E] Nuc 1:1 CW#4GE .00
Bualneas and Professions Code.)
wal THE MTErDaD uJel or THE euNLosa eY THE APPL.KYWT OR NvnlRe 5■n■.o
ocouRA IR FCILIAL e A PEFeaT Nvn corenMSCT OCINpa OR caoax Puw nNG THE soLrrN -- 1 11/ 1I Q
CONSTRUCTION LENDl7�lQ AGENCY cnAar Asa oLwlry uwnAona3aT DueTTrcr lenAoiof SEE PEfearna oFacrarar-
FVR GUIDELINES.
1 hereby affirm that there Is a oorstnx:rion Wx*V agency for Ym❑ Na El
e performance of the work for which this permit Y ineued(Sea Fs i H^V READ TFIAZAROOLC rverrALa ra'ORWUION GLIDE AND THE eoACMID 1 11
to
0 3097,Ctv.a). PEFeaTTMe CI-�.I UrDMIZOVD W F993LIFI%RWRI MOM THE L06 ANCFIee .
�. CCLWrY CODE.TMJR s CHAPTER L20 seoTKM L3ELIM THFAD F L3nl.o CCHOCffiM
Ladders Name FMZMDOUe W07ML 8 REPORTMG AND POR oaTAMIO A PEfsaT MOH THR SC041D.
Lenders Add rem
I certify that I have read this application and state that the above RC FEE Pl�wc FEE
InfDmstion is ou
correct. I agree to comply with all orrty a
ordherIces and State lawn relating to buUding constrvotlon,and
hereby authortm representadvea of this County to enter upon ISSUANCE FEE /
the above-merrtloned property for Inspection purposes.
se M/ESTIOATION FEE TOTAL F
�,r�rArp�.rrA� o+.
So RJEWERM POR EXPLANATORY LAlIOUAGE
COMPQJSAT}ON DECIARATtON '
hereby rm that I have aers' ome of consent r elf APPLICATION, FOR WILDING PERMIT, -I
Insure, or a certificate of Workers'CompensdTlon Inlutance,or a certffied copy thereof (Sec 380¢, lab. C.)
COUNTY OF.LOS ANGELES BUILDING AND SAFETY
Policy N0. _Company y
Certtfiod copy Is hereby-furnished. FOR APP-LICANT TO FILL IN
'Certified copy is filed wlth.thb county building Inspeo- BUILDING
tion department. ADDRESS O L LOGAtm L.
NEAREST
Date�b- r- Appllcabt QTS L ZIP CROSS ST. /1?
CERT fl., TE OF DO MPT1 QRS" SIZE OF LOT ON BOOK PAGEPARC
COMPENSAWN I UR,ANC>
(fhls rgcTlppn need not be,c6 leted,l#the permit is for one -' USE ZONE
AAokP
hundred dollars(;100)br 1ess7 r , TRACT B10CK LOT NO.
f TEL' }
I certify that In the perfdrrrignce of the work for which this OWNER
permit li lWed, I shall not employ any Person Iri any manner ADDRESS
ISTRICT GROt1P TYP) FIRE, PRO BY 0"
so a;to become sublect to the Workers'Compensation Laws. CONST. Z V
-
Date Applicant ARCIifTCi T OR CITY. ZIP Ta-
Exemption,
ka,
T� V
NONCE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' �' CLA55 NO. UNITSCL
LU
Compensation provlslons of the Labor Code, you.must forth-- gyygt MAP rh
with comply with such provisions .or this permit shall be ADDt�55- Z
deemed revoked~ COtJTRACTOR NO. BK PC3,. VAiDATLON
LICEN&D•CONTRA("TORS DECLA1ZATlON
I hgraby 6ffirtn that I am Ilcenaed unlet provbiora of Chaptir 9 NO. VALUAT}ON
(comfnencing with Section 7000)of DtvWon 3 of the Business q'nd
Professions Codd, and my license b In full force and gf e.4 CITY �}-- CLASS �.� $_ �C
w SQ NO.OF NO:OF CHS` , r:
LlcenseN4mber�4 �--u,.'
lc G SLZE STORESI CNE
r
_CootroctorC► �-+ Ml L��,/ Date flE5Ci21PTION OF'WORK
I am ekempt-under�SeG HADD
ALTF3t 0 FINAL
B.&P.,(-- srt for this reo
REPAIR [JAYS
Da1o• 1 SE OFG BLDG. DEAhOL . Q a9NlAL
by
Signature $ - APPLiC.4N7 TFL
'
OWNERUILDER DECLARATION
I h"by affirm that I am exempt from the Contractors Ucense e
>�,T ( _
Law for.t4 following reason (S*c11or1 7031.5,.Blnlne�and ,
Profetslons Code):
11 as owner of the properiyr or my employeer with ADDRESS -
wages as their sole.compensotion,will do the work and
the structure is not Intended or offered forsale(Section tOC11lTY
7044,'Byalnea dncf.Professions Code}. MOVINGTEL
I,as owner of the property, am.excluslvely controcting OR �'
�. :' �05,2A'
with I((cdnsed cQniroctors to construct the protect (Sec- .
tion 71344,$uslnew and Professions Code). ADDRLSSr
CdNSTRUCTIOI4 LENDIN&AGENCI SE7 IRID YARD ' TOTAI�� U FROM TM •° ° s ° ° 1
I h.eref�y affirrp that there Is.a:consttvcifon lending agency for FST i
the performance of.the work for whidr this permit.Js Issued
2,Q 1.1 .5100
Sec.•3097,,CIv. C.} SJ DE 10
°,1 :1:I 0 ZTS
'P.L .
Lip 'P.
Ndma (12,1 =8:2
Lender's Addrees P.G Fee Permit Fee i
I',certtfy that I have read thR hppllcc lon and state that the hW_k W*Pee
above Information Is correct. I agree.to comply wtth.all County
Investigation Fee
ordinances and ,State laws relating to building comdructlon, . Total Fee
a hereby auThlor1ze.representatives of this County to enter
bov property for Inspection purposer
>�RNIf!N�R KXMANATORY
4g7a re m Dare