HomeMy Public PortalAbout6342 TRELAWNEY AVE_Building_4/13/1995_chimney work I _
APPLICATION F913-BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO RLL IN - Bull-g(yp��
I hereby affirm that I have a certificate d consent to self insure �e�
or a certificate of Workers Compensation Insurance or a certified
copy thereof
(Sano 380 LLabb�C) `. 4' Nye ,� Cm G` ZIP
POIIL/Ngo `_—� C.anPsM,St '��' " I17CAIJTy
SIZE OF LOT NO OF SLOGS NOW DI LOT
❑ Certified copy is hereby furnished I NEAREST CROSS ST
❑ Certified copy,is filed with the county buildup inspection TRACT BLOCK LOT NO
rat '(/n, D C�t� �( USE ZONE MAP NO
Date Applicafll ! e-Rf,, �) — ASSESSOR AAP 8001( PAGE PARCEL
N I SPECIAL COMMONS
CERTIFICATE OF EXEMPTION FROM WORKERSTEL
GWN R
COMPENSATION INSURANCE YnTFUN 1000 FT OF SCHOOL' YES NO
ADDRESS
(The section deed not be completed d the permd afar one hundred �• 1 DIStAICr GROLP CONS! FIRE ZONE PROCESSED BY
dollars($100)or, less) CITY ` LP
I certify that In the performance a the work far which tins permit �O�
is riled I shall not employ arty person In ary manner so m to ITE&RCHOR ENGINEE TEL NO
M*Lbecome subject to the Workers Compensation Lawn SVTRSnCALCLAM AD AI'T CONDO
Date Appllcafll ADDRESS CLASS NO 1 UNITS
NOTICE TO APPLICANT It after making this Certificate of REOIIIRED TOTAL SETBACK FROM EAST
Exemption you should become subject to the Workers �, TEL NO_ SET BACK YARD HWY PROP LINE WIDTH
Compensationrs
provsloof the Labor Code you mat forthwith
FROM
comply with each provslons or the permit shall be deemed revoked LIC nq P L
LICENSED CONTRACTORS DECLARATION �" SIDE
LC PL
I hereby affirmthat I am licensed underprovelons a Chapter 9 — SEWER MAP
(commencing with Section 7000)of Dnnslorl 3 of the Business and SO FT S17E NO OF STORIES NO OF MtUES Ips
Professions Code(�and my license a in full force and a NEW PqC BK PG , d
License Number i--A-T"'Q' Lc Class �� DESCRIPTION OF�K ADD ❑ vALOAnON _ O
Contractor to �� %emOU ALTER ❑ $ U
4 �
❑ I am exempt under 11 under Sec � $ 1
RBPC for the reasonCNS t. DEMOL ❑ LDMA PRC• AL l ' .i W
Date USE OF FXf nhQ TO URM ❑ - l (-
L 313 037 yJS.1Q)
Signature TI � / NO LDMA Perm• Z
n nsa
l LJA� O I1 EM z 1
❑ 1 as owner of the property or my employees with wages as TOTALTL 1i - 1 j
thesole compensation will do the work and the structure E S
not intended or offered for sale (Section 7044 Business and1-6jWyA1 FL r FINAL DATE G
PrCHE ie7.Professors Code) WILL L TIE APPUGM OR a -W occURWr w DIE A INZAiDOIIs WTEPA- �j n .
K c
❑ 1 as owner of the properly am exclusmey contracting with OR A MorruE coNwMING A IlA7AMWe MAT COUAL To OR prEATEe T TIE
FIN9a
AMOlM9 6FECiID ON TIE NAZMOOUa IMTEPW.4 NFC0.MATI6n ouDFINAL
licenseBusid
contractors,
to
construct the project (Section 7044 mss❑ No 4b NANVE .CL)
M4 THE MENDED USE OF TIE BUpLNO BY THEAPPLICAM On FUTURE BULLDNO
COAST AIR OUAIIiY AInI GEI.ENT pQrBICT IeCAD l am PEawTNAE C1 Muv Poo I
CONSTRUCTION LENDING AGENCY ouDEV a )71JU-1!1!1)1 4/1�i5!
I hereby affirm that there Is a construction lending agency for YEs❑ No W is i nM 9:23
the performance of the work for which the permit a Issued(Sec
m 3087 CN C) ciEau l'"EirDEesDa+D w a u a TINE t uioEUE�s�Dcotp rY cooE
Lender a Nerve w 2 rwE xn WcnoNs z rico A cI ouiAToiEec oA�'io"16IUZAr+oas
Lenders Address
0
I ceNity that I have read the application and state under penalty
g of perkuy that the above information 9 correct I agree to Comply PC FEE PERM T FEE / /.Q
with all county ordinances and Sate Laws relating to buildingG ✓S
S trucign and hafeby aulhome repnesentatws of mis County ISSUANCE FEE
21 r P n t B nT aratl property ar ma 1 r V�•I/(O s
I INVESTK3ATION FEE TOTAL FEE
m a J
o.. SEE REVERSE FOR EXPLANATORY LANGUAGE