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- WORKERS'COMPENSATION DEQARATION .
I hereby affirm ihai I hpve a certificate of consent to self APPLICATION FOR �UILDING PERMIT
insuro,or o certificale oF Workers'Compenstion Insur�nce,or
a cerefied<opy rhereof(Sec.380D,Lab.C.) COUNTY OF L05 ANGELES BUILDING AND SAFETY'
P❑ollcyNa Company _ _ r.,.
Certified m "s hereb furnlshed. BUILDING„ �" �
y rr� r FOR APPLICANT TO FILL IN nooRess . `.7 � YXC�- 'S"Z t
Certified copy is flled wdh the county building inspec BUILDING � "� � �
� � ro�dPPa��me�r. ao�Ress,�.�!�� litJ�C1CbJ YK�r �ocnuTv ^�i �-��r,t� j"
� �d�ry NEAREST �� / �
Date Applicnnt CITY 1 Qr�� t r4���• ZIP �ROSSST, V�/�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS, a55ESSOa
� COMPENSATION INSURANCE SIZE OF L(7T NOW ON LOT MAI'BOOK PAGE PARCEt
(This section need not be completed if ihe permit is for one IRACi BIOIX LOI NO,��p"'J� U,�E..�Op1E MP,P {�'� __-`� .-�,_
hundred dollars($100)or less.) �' f �� �"
TEL. ) (��) SPECIAL �
I certify Ihat in the performance af ihe wark for which this OWNEK NQ�l�C%"I��u CONnITIONS (�
e mit is issued,I shall not em lo an erson in an manner ' DISTRICT GRUUP 7vPE FIRE PROCESSED BY {,J
P-� P Y Y P Y ADURFSS f` . � CONST. � �_ � �
so os to bocome subjeci to ihe Workers'Compensation Laws. �`y � ��i,_,��r^sL; �
� c� � �
CITY Ji�Ka~ ZIP ��
� Dale Applicant STATISTICAI�LASSIhICATION c F� APT. CONDO.
ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making ihrs Certifi<a1e of N�. �4`��'�4i ;;�qSS NO 4'��C� DWeLL.UNi75_' �
eNcwrER Rl�i. ��+�''
Exemption, you should becomc subjeci �o the Workers' »'S
Compensation provisions oi the Labor Code,you musi forth- �DDftt55 SEwEIt MAP �
wiih comply w�h such provisions or this permit sholl be
deemed revokod. ir�- BK PG. VALIUATION
CONTI2ACTUR NO.
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm thnt I am licensed�nder provisions of Choprer 9 , AO�R[55 NO. VALUATION
(commencing with Sadion 7000)of Division 3 of thc B�slness nnd ' UC
Professions Code,and my license is in full force and effect. CiTY CIA55 S� ��`�7
SC�.�T � NO.Oh N(1 OF CHF.CK
�i�ense Numher Lic.Class ' SILE ��~Z7 STORIES l FAMILIES ONE
n NFW �
Contructor Datr. DFSCRIPTION OF WORK ' ��R it�
❑ -t+ AUU �
I am exempf from the Ilcenslnp requiremeNs as I um q /(J CL?ti�'r/hlC1E; GI..�C)K K- o �J
� licensed archifect or p registered professionol enginr.n,r �� � A�TER � DA E` � R7 n(, ,
a�rnq '�r, my p�ofess���ai �apa<ny �saa�o� �as, t"KC1i--7 ���'.� �7 � sePniR ❑ � �
� Business and Prolesscns Code). USE OF � p{ryq�
F.KISTING fiLDG. [7FMUt
Lic.or Reg.No. Dqte BY
APFLICANT iEL ')'iti�
}}k,, OWNER-BUI�DER DECLARATIUN ,PRiNT}+� D� n.r NO. ty l'I7 .--�
� I hereby aPPl�m Ihnl I am exempt�rom Ihe Contraclor's License c�- � � �
Low for ihe following rensnn (Section 7031.5, Bus�mess and !��kt55 �4����� 9 -'���G���f•
Pfaf IonS COde�: PRFSFNT �✓ ��f� t
n eunoi:�c M �;t; o • . ,�3
P I, as owncr of thF property, or my ertipinyees with A,�DRE55 �r�'7✓ �� ,r
�ayes as iheir sole mmpensa�ion,will do the work�nd �'. Ary� j�e r.,lY+�(��
the structure fs not in?ended or offered ior sale(Section tOCaLiIY . � �r�,
7044,Business and Professlons Codel. MOVWG T<< ' ��'// /�/ # ��'�
� I,as owner of the propeny,am ezclusively mntraciing CON7RACIOR NO -�� �i •�'i1�Ri -
� with licensed contrauore to censiruct ihe projec>(Seo qpuaetis �[7 Jp +�a���1��'Q
tion 7044,8usine.ss and Professions Code). J
� aEnu�RFo vnuo r+wv TOTni sFTsna Fkonn exisi. : •a s 7 3,5 0`z-'
CONSTRUCTION LENDING P.GENCY SCT 6ACK PROP.LINE WIDiH #f
I hereby affirrn ihat there is o mnstrucnon lending agency for Fgp�iT `,
ihe perfurrnance of ihe work for which�his permit is issued v t ��7 �� � �� `S�8�
(Sec.3097,Gv.C.). SinE "'�
�� /'�/�JFI�<
Lender's N�me _ .
z sz' � I
P.c.ree 5 ..?.,...'"'_ve�ma Fee (,y°
. Lender's Address_ {�
�7 ,. Cl ,Y'/
� � I certify that I have read ihis applicatlon and state thnt the saaonce Fee -
Q above informatlon is mrreci.I�c�ree b comply with all County Invozn�mion fee
ordinances and State lows relohng l0 6udding consiructlon, Imol Fee
and hereby authori�e represenlotives of ihis Coonty to entnr � �
�; up ihe aba���-rrie ioned prope insper.lion purposes.
�Q�e''� � �r'�� f,� �e� �f SEE REVERSE fOR EXPLANATORY LANGUAGE 5
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