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0124A (4)
WORKERS'COMPENSATION DECLARATION ���� '� , I heie'by affirm that I have a certificate of�o�,e�,,a self p�AT I O N FO R� B U I L D I N G �P E RM IT � insure,or o certi(icoie of Workers'Compensatidn Insurance, or a certified copy thereo((Sec.3800,La6.C.) ... _ COUNTY OF LOS ANGELES ' ' ' BUILDING AND SAFETY Policy No. - Company � , BVIIDING `� fj n �__ ❑ Certified mpy is hereby fornished. '' � O A T FILL IN ADDRESS '� ,Q�i c.yit.��.�,1� ❑ Certified topy is filed with the county building inspe �� q �� � �I � . tion department. �- � �. ADOREu.( d D � Dafe �- ApplicaM . . � � Gltt 1 R �.OF BLOCiS. NARES - . CERTIFICATE OF EXEMPTION FROM WORKERS' � 512E OF LOT NOW ON lOT � CROSS ST. " COMPENSATION INSURANCE - (This setlion need not be completed if the permk Is for one TRACf - ��� � BIOCK � - iOT NO. -� -� �� A55ESSOR . hundred dollon($100)or less.) �P�K - PAGE PARCEL TEL. USE ZONE �P � ' OWNER LnRR LR ga/���-��-NO. (rl���oL.O NO. III-3�I ��1 Eertify�hat In Ihe performance of the work for which tBis � . permit is issued,I shall not empioy any person tn any monner � ADDRE55 S� �� � �• �� - SPECIAL } - so as fo 6etome subject 10 1he Work Compensation Lows. CONDITIONS � O � ��'.'�,&e7 CITY � � ZIP . . _ . .._ . .. ,. . . . . , . . . U Data � Applicon � - ARCHITEC7 OR 7E�, K NOTICE TO APPLICANT; If,�ofter maki ihis CerfifiCafa of ENGINEER�- � .. � _ DISTRIQ � GROUP TYPE� � - FIRE PROCESSED BY � Esemption, you shouid betome su6ject �o the Workers' �� /A CONST. ZONE - �- .Compensation provisions of tha labor Code,you must forfh- ADORE55 _ /v� � w with comply wi�h such provisions or this permir SIIOII b@ .-�' ' TEL. $TATISTICALCLASSIFICATION APT. C Noo. '� deemed�evOked. . [ONTRACTOR 4>>t,�2 No. Spl hE - - - - � Z UCENSED CONTRACTORS DECLARATION - LiC. CLASS NO.�DWEtL UNRS I hereby offirm fhat I am licensed under provisions of Chap�er9 AOORE55 � S�H � NO. LIG. SEWER MAP (commencing wi�h Seclion 7000)of�ivision 3 of the Business C�, �� and Professions Code,and my license is fn full forte ond eifect. , . gK pG � VALIDATION. SO.FT. / � NO.OF NO.OF CHEIX � - . ��- License Number Lic.Class � SIZE � )C�'3 S70RIE5 FAMIUES ONE . � . � - � DESCRIPTIONOFWORK p. �p �VV�Q N� � VALUATION _ _ � _ � Controttor . - .. Dafe � _ . . . .. . . S �rDv .. . . . . ... .. . . AD�� ❑ ,. ❑I am exempt under Sec:� AITER ❑ - - � 9� 8.8P.C.for this reoson REPAIR❑ s . . . . �Dafe: � - � EXIST�ING BLDG. . .. . - . .-.. . . DEMOL❑ .. . .. . . . g Q t 2- a 9 APPLICANT . . - #i,� � . �� . . $i nafure (PRINT). .. . �,�j�p: �� FINAL C OWNER•9UIlDER�ECIARATION pA� ��7�� � I hereby affirm that I am exemp�from the Comractor's License � � � - .... ... .. . . .. .... � � . #I� 6 7 5 Law for the following reason(Section 7031.5, Bosiness and ADDRE55 FINAL^L� - � i • • • :� . P�qfOfe551005 COd@J: � � PRESEN7 - . . By � -- - � ' —'L�l I, as owner of Ihe properly, or my employees with AO RE55 5 0 3�8 9 . - apesac�hoirsolrcompensation,willdo!hewo•kend . . . - . , . the structure is not intended or offered for sole(Section ��A��TM � . � 7044,Bosiness and Rofessions Code.) � - MOViNG � - � - � �� ��� TEt.�-� � - � - - � ' - � ❑ I,as owner of the property,om extlusively contratting CONTRACTOR NO. . � with licensed controctors�o construtl the projetl(Seo- -. .. . ... . .. . .... ... . -. -.. . .. .. . —.- . ..' . ... . .. . -.- . fion 7044.Business and Professlons Code.) AD�RESS � � �O� L D A` � � �REQUIRED TOTAL SEiBAIX FROM � EXISI. CONSTRUCTION IENDING AGENCY � - SE7 BnCK YARD HWY PROP.LINE WIDTH #R r � • •� - I hereby affirm that Ihera is a tonslrudion lending ogency for FRONT ihe performance of�he work for which this permit is iswed � �P�L ' '� � � I r�3 6 7 5 ($eC.3097,Civ.C.). SIDE . .. .. P.L .. . . . .. . . .. . . lender's Name �N��3(L 7 Jr F� - . . . . . .. . ..... h`��- LDMA Ref.k._ _ . � - P.G Fee E Permit Fee �G � a s o 3=a 9 Lender's Address � , : _ . -90. ,f� _ _._. I certify thof I have read this opplimlion ond state tha�the � Issuonce Fee LDMA P/C M � � above informalion is correct.I agrea to comply with all County in�eeuqaiion Fee. / , � ,� ordinances and Slale laws relaflng to building construc�ion, � � io+al Fea �b �� LDMn verm.p � � and hereby authorize representafives of this Counfy to enter . opo t e obove•mentianed property fo�inspeUlon p�rposes. � � � � � �� � " � � � � � � X QAa.r d�3�� : SEE REVERSE FOR EXPLANATORY IANGUAGE _ _ _ � � Si iure of Applicom or Agen� Do�e . / . y,, ' . • ; y. '1 ° o �.-a' o w o id �'m .. 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