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hereby
ed Ro that
IIOhofve5 a certificate
ION DECLARATION
APPLICATIO - y of consenLto self N FOR- BUILDING PERMIT—— ips re or a certificate of Workers Compensation Insurance
PY ( 3800, ab. C.) " ' - .
PolicyN 99(E7JL@empony, .D COUNTY OF LOS ANGELES BUILDING AND SAFETY ,. •t;
Certified copy is hereby furnished. •
Cert f edcopy'is f ledwiththe county bustd ng mipec- --
tion department
Dote7- Applic&
CERTIFICATE OF EXEMPTION FROM WORKERS' - -
COMPENSATION INSURANCE' - '
This section geed not be completed if the 'permit Is forone--
hundred dollars ($100) or less.)
certify, lhot,in the performance of the work for which this
permit is issued, I shall not employ any person in any monner ----
so as to become subject to the Workers' Compensation Laws.
Dote'Applicoal —
NOTICE TO APPLICAW: If," after making' this'Cerliflcate of
Exemption, you' should become' subject to `the' Workers'
Compensation provisions of the labor Code, you must forth-
with comply- with such provisions or this permit shall be ----
deemed revoked.,, -
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of, the Business and
Professions Cod , and my license is In full force and effect,
License Numbed Lie. Gloss/l'
Controctor l v "'++Date a.R'.
am exempt under Sec.--
P.C. for this reason
Do
OWk R- UILDER DI!CIARATION
I hereby affirm that I exempt from the Contractor's License
Law for the following' reason (Section 7031 .5, Business and
Professions Code):" .__ ...... ........ _._...___..... ----.
I, as owner of the property, or my employees with
wages as their sole compensation, will do the workand
the structure is not Intended or offered for sale (Section
7044, Business and Professions Code). ---- -
F, t, as owner of the property, am exclusively contracting
with licensed contractors to construct the project -(Sec- -
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING -AGENCY'
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued- -
Sec. 3097, Civ. C.).
lender's Name
Lender's Address
I certifythatA have..readthis application and state that the _
above information Is correct. 1 agree to comply with all County
ordinances and State laws •elating to building construction,
and hereby outhoriz r resentatives of this County to enter
FOR APPLICANT TO FILL IN
ADDBUILDINRESSG
BUILDING a3(ol Ph 61 ADDRESS D fl s p
1 -.. CITY l I ZIP LOCALITY
NO. OF BLDGS: ...._.. _,,. NEAREST.___...'. _•.. __..
SIZE OF LOT NOW ON LOT CROSS ST. ,
ITRACTBLOCKLOTNO.
ASSESSOR ...
MAP BOOK PAGE PARCEL
LOWNERV`iI(J a 'd t `' AMi-'-
NOTEL-.
gS'Oliy( USE ZONE MAPAMNO
ADDRESS aZJ rIlii Ylh Oa't SPECIAL.. .
CONDITIONS
CITY ... IIs'/ __ ZIP _
i
ARCHITECT OR
ENGINEER
TEL..DISTRICT
NO. GROUP. TYPE _. _ .. CONST FIRE...
I ZONE-
PROCESSED BY
ADDRESS O --.
CONTRACTOR '
J S5o(TE0Lhjq 1•CaU STATISTICAL CLASSIFICATION
CLA55 NO. _ DWELL. UNITS
APT. CON00. -•
o .' .. ... . , LIC.'
ADDRESOM1 L C NO.
1i 6.. LIC. - q
SEWER MAP
CLASS '1 BK .__.. _ ..... ..... VALIDATION.._.
SOCITVFT. NO. OF. NO' HECK
SIZE ---- STORIES FAMI101ES- - CONE
VALUATION OC:..
Qyyl.7
y- DESCRIPTION OF WORK led li- _ ._ .___ ... - NEW --
at ADD
ALTER
11 LL) LL
REPAIR_
USE OF
eEXISTINGBLDG. L DEMOL
FINAL
DATE
APPLICANTPRINT) 111• N MILL Asrsaa
CIK-de `QMADDRES9'a;;, aLJ 134 FINAL -
BUILDINGADDRESS'
zg 5 5 9.. 2 A. . LOCALITY
MOVING_..__ .. ._ -. .. ----TEL.- TEL..
CONTRACTORCONTRACTOR NO. 1 -
C 8 Q go
I •... ` o Q CVJ
ADDRESS
SETT BACK YARD HWY TOTALPROP. UNEFRO WIDTH.
FRONT
P.t. 01.3D--87
SIDEP.L.
LDMA Ref. M
i... ._ '. .
P.C. Fee E Q `('R, Permit Fee - Q!0
P/CIssuanceFee _1O.• ._ .'
Investigation Fee
Total Fee - .. . LDMA Perm. If
U t a -men ' ed r perty for Inspects
SEE REVERSE FOR EXPLANATORY LANGUAGE I i
ignofUre of Applicator Agent .__ .-__. - .. Dote_,
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