HomeMy Public PortalAbout6335 TRELAWNEY AVE_Building_10/22/1991_40172 roof A APPLICATION FOR BUILDING PERMIT �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKEWS COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDR
I Irnebr affirm that I have a certincate of consent to esti insureGµ,0 .SASS zeez o w6-Y
or a certificate of Workers Comperoetlorh Insurance,or a certified ��r 3, T�Q E L f)w/VY �Em�L E C•F/� �i� gj7�a
copythasof(aecaeoo,L�c�,rsSdEm.'c6 c°.7r 9/7da LOCALITY
pd�,No Q�= 9O Company STA76 1 ✓v SIZE OF LOT NO OF&.DOS NOW ON LOT
❑ Certified copy Is hereby furnished NEAREST CROSS ST
Certiffed Copy m filed with the County building Inspection TIIACT BLOCK LAT NO LEmOiy
IM
ASSESS L13E ZONE MAP NO
department
Data /°-"'90 Appirant YILZORL NEdAtAtDEt _ r Br 0E �yyoAARbCELL
OW N� 2 �-� SPECALcoFminoNs
CERTIFICATE OF EXEMPTION FROM WORKERS' /11AL.f YA4 Eignla � ? - YES IAO
COMPENSATION INSURANCE WITHIN 1000 FT OF SCHOOL?ADanESs/
(Tits saebon rsetl not be Completed Hint pennrthfor one feuhtlned 633.5" //26LAsV.VEi DISTRICT GROUP TYPE CONST FIREZONE I'ROCFBSED BY
dollars({100)or lees)
I Cerdfy that in the performance of me work for which this permit Cm TEm.' p'L E L'i TY 7JP 9/7�s !OG -3
h lowed I "I not employ any person In any maraEr w as to ARCHITECT OR ENGINEER TEL.NO
become hu b9act to the Workers'Compensation Lews STATISTICAL ClASSI/FFWXrC I APT CONDO
Dese Appley1i ADDRESS CLASSNO �1DWELLUNRS
NOTICE TO APPLICANT If, after making this Certificate of pq .�c REWIRED TOTAL SETBACK FROM EAST
Exemption you should become subject to the Workers J J L TEL NO GQs SETBACK YARD INN PROP LINE MOTH
Compensation provisions of the Labor Code,you must forthwith M1, C
comply with well provisions or tills pwmd shell be deemed revoked LIC NO r
FRONT
11.943 �iicL/An[ ST- cy�Sy PL
LICENSED CONTRACTORS DECLARATION
CITY 6 (+<I- LIC L"-3 9 Pl. S
I hereby affirm that I am bDwtwd under piovldons of Chapter B L /. aevr SEWER MAP
(commencing with Section 7000)of Dtrmm S of the Business end BE) FT SIZE NO OF STORES NO OF FALILES z
Prolroeions Code end my I s In futi fo1Ce ere eftxt /Soo / / NEW ❑ BK PO ,
License Number .Jb 72Y3 � pan e-391 D�RIPNON OF WORK ADD ❑ VALUATION
Contractor [bemZ //FaA4,x /O-P2-90 EMO✓E �vJri�v� 20✓F�✓B ALTER 11 _ /S-00 z
.zE-JA/EE7 .200E w/. '!Jr /TL1 Iff
❑ I em REPAIR exempt under Sec ❑ $
B aP C for this reason &,4Jcv' �300OltJN••
ASJ :4� vBce-t DEMOL
119E OF Mr BLDG IDMA P/C
�e APpLICwJr/fryL/mENgL,L.�/ `° URM ❑
Sia ovin \he-va 1C - 4Ee2n1 350— 26 r LDMARem e 1 AT
❑ I, ee owner of the property or my employees with wages m ACtT.r
nottheirsale ed or
tloRh for
do the work and the aWCWro b F
not Intended a ortered nor eels (Section 7GaA, Business and 1925 kIu-I.aAr EC rtfd.t,7-� !�A- rouLDATE 7� a X007 79.3
profeeNam Code) rias„s,anucwn.wwhurseuunwaoccz.eNTNua.sAhavAnaoumNArwAL /D 30 — 2`L� °
oR A FmnhxRs wNrA..n A rhANu+Doue rArvBAi EQUAL ro oa orEATEB rFhAN 1 ITD;-
❑ I ns ower or the property, am exC11mW'eelY COntraCting with MAMIxIMaSPEaT®aN TIEIWMDDIm FrArFinae lNfCxiWll(:11 WADl9 FIIW. ')
licensed contractors to construct the project ISecdon 7044 Yrs❑ w❑ FEL D TOTAL 70 . 38
Business are Profeaalons Code)
rn.L THE RNhvIBEn vee or rhE ewuolNo er rhE AIRIGVIT w nRruE IxROerO
CONSTRUCTION LENDING AGENCY occuswrrRcrouaa:APEmrrwacorsrFORW� VCTMCA L"SCE wrleNnw,.saourN �� CHECK �U.�_
Corer AE olasLm•.•�:sT<,.c:CrBmRCr terwaol SCE relNrrnq CFIeCatsr
1 hereby affirm that there is olerhdi
a construction ng agency for YES 11M❑ I.HANE
me perfomunca of Urs work for which tNe permit b homed msec I Hove READ TW huZMDOIE uATBWLLa erPoIBLATON ouDE AIO THE SCADND
9097 CIT C) PrseTnexi CFECAIer I lxWmrAND rrr BaOUTETe31re HOER TIE LOB ANDEIEe
Lender's Name
LendsYs Address w.uaAmT 3435 1 A1110::4
0 1 certify that I have read this application and sada that the allows
Infornedon Is correct I agree to comply with all County PC FEE PERMIT FEE
ordinances and Slate taws relethg to building mnwu ction and
nNwAze representatives Of this Courcy t0 ether upon ISSUANCE FEE /
\1 a ew a Toperty for Inapectlon PnuDDees
IO r,Z-9J INVESTIGATION FEE TOTAL FEE
..... ._ p. o. D.
at
BEE REVERSE FOR EXPLANATORY LANGUAGE