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WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)
Policy No _ Company
❑ Certified copy is hereby furnished.
❑ Cert;t., ipy is filed with the covwy building inspec-
lion -;!ment.
Date___ _ __Applicant,_
I11-ICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(T.),s se(linn need not be completed if the permit is for on
Irund,ed dollars ($100) or less.)
I certify that in the performance of the work for wh' h this
permit is i6sund, I shall not employ any person in any �isa ner
so as to theeenme subject to the Workers' C n pens aws.
NOTICE TO 1\PPLICANT: If, offer making this Certificate of
Exempl,00, you should bt:ceme subject to The Workers'
Compensoliun pro: isrons of the Lnhor Code, you must forth-
woh comply with such provisions or this permit shall be
deomed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm +hat I cam licensed under provisions of Chopler 9
(cornmencinq with Snrtion 7CYX)) of Division 3 of the Business and
Professions Carle, and my license is in full force and effect.
License Number f Lic. Class
ConlroclwrL- �y i r Date
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
octinq in my professional capacity (Section 7051,
Business and Professions Code).
tic or Rea No. Dole
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
❑ 1, (is owner of the property, or my employees with
wages as their sole compensation, will do the work and
lho structure is not intended or offered for sale (Section
704.1. Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting
with h(ensed contractors to construct the project (Sec -
lion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby nffum that there is a construction lending agency for
the pert,+ v� nre of the work for which this permit is issued
ISec. 3097, C,v C ).
Lencler'5 Nnrme
.i lender's Ad+vss
W I certify that I have read this application and state That the
' nbove mforination is correct. I agree to comply with all County
n
ordmnnces and State laws relating to building construction,
and hereby nuth representatives of this County to enter
:a�n I tn one perry for inspection purposes,
/ . 1111,761
S a^ai 1 Aon'qom or Anent Date
APPLICATION
FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING ( r
ADDRESS
CITY d"/
NO. OF BtDGS. / \
SIZE r?f LOT NOW ON 1; r
TRACT—,!', ' ✓"2" BLOCK lr'T n10. �/ O
+ Tc! i
owNFR 1S/i ,t'l Y e c/,.�e-1 NO.Sy'y 5'in 3
ADDRESS / 7/7
CITY P4/�/� ZIP
ARCHITFCI OR TEI, '
ADDRESS
COt`ITRACTORLj7L i%�+ T�/yy Lt�i(f1 4 =' .
NO, 0% d
UDRFSSj tf4/ l L'%✓ X;y��
NO 77J `rf
CITY
Ct CLASS
SW FT �
SIZE %�
NO OF
STORIES
NO OF
FAMILIES
/
CHECK
ONE
DESCRIPTION OF WORK
NEW ❑
ADD ❑
�t�n1
ALTER ❑
REPAIR ❑
USE Of
EXISTING BLDG.1 IWI' ��rf!%/�y �
DEMOI ❑
APPLICANT / / � �)
(P,/� yG
.RfNi)
NO
ADDRESS
PYLN111
BUILDING
ADDRESS
MOVING
TEL
CONTRACTOR
NO
ADDRESS
REQUIRED
YARD
HWY
TOTAL SETBACK FROM
EXi5T
SET BACK
PROP IINE
WIDTH
FRONT
PI
SIDE
PI
P C Fer $
/!J ��
Pc•mtit Fee
Invvshgatinn Fee
loot rev
SEE REVERSE FOR EXPLANATORY LANGUAGE
BUILDING
ADDRESS
�� 7
LOCALITY
NEAREST
CROSS ST.*[+c
AS'S SSOR
MAPNOK
RA
PAGE _
NO
0 0 " 1"I I CONDITIONS
DISTRI T
GROUP
TYPE
FIRE
CONSL.--
ZOt
/�`"'""
r
e�,1 l
1
STATISTICAL CIA5SIFICAIION
CLASS NO _ /—DWFIL. UNITS
SEWER MAP
I
BK PG,
VALUATION
$ �� 4" /1-2'
$
FINAL
DATE
FINAL
By
/,1'r K- c)
APT
VALIDATION
