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1457A 1458A (15)
WORKER$'COMPENSAT�ON DECLARAiION � � � " � � � � I hereby affirm thot I have a cerrifica�e o,�o�,e�,�0 5e�� - APPLICATI4N FOR BUILDING PERMIT �insure,or a cerrifico�e o(Workers'Compensatlon Insuronce, or oSCrJr�i d o y the eo(�(Sec.3800,Lab.J C.) T ( CpUNTY OF LOS ANGBlES 8UIIDING AND$AFETY Po�I�yNo.��6��lOmp��Y'�td4���'C0.1 .1hQ�'t•I1� BUIIDING �1 p�[� t41{�O� �Jqr'(Z � i f ��rrfied topy�s hereby i�m�shed. FOR APPLICANT 70 FILL 1N ADDRE55 O�a � ❑ Cerlified copy is filed wilh Ihe counly building insp� ADDRESS ��S��a��� �r��� lion depa tmenl. � (' (� Dofe � Applimnt G[Y �10."�cK�C1 1JQ'✓. ZlP LOCALITY ���� Qf -7 C RTIFI ATE OF EXEMPT N F O ORKERS' y Sa� NO.OF slDGS. � NEAREST 1 l�f� COMPfNSAiION INSURANCf SiZE OF lOT D^ I rIOW ON i0i CROSS ST. � (This seciion need not be tompleted if tha permil is for one .. _ ASSESSOR 7gpCT BtOCK LOT NO MAP BOOK PAGE PARCEL hundred dollars(EIOOJ or less.) /� / TEi . y� . OWNER dN(� 07 �M��I CA NO. Z-L$"77 $E ZONE MAP . - I terti(y fhal in Ihe performance of fhe work for which ihis ♦ ) y� j �- permif is issved,I shall nol employ any person in any manner A�bRESS��J. �/��P�✓ �/'� �1� CONDITIONS �� � so as to become subjett to the Workers'Compensa�ion Lows. Q ) 0 � . � CITY Il �p"S ZIP /D n�/ ' � U � DafC � � AppllcaM ARLHI7EGT OR TE�• DISiRICT GROUP TYPE FIRE PROCESSEO eY O IJOTICE TO APPLICANT: If, ofler moking this Certificme of ENGwEER Na� � � CONST. ZONE "(�^ V Exemption, you should become subject.�o Ihe Workers' - -- I (�. ^'��— �`�,\ Campenza�lon provisions of the Lobor Cada,you muse forth- qppqfu J �- � with comply with such provisions or this permit sholl be �"� �, STATISTICAL QASSIFI ATION � APT. CON00. (n deemed�evoked. �ONTRACTOR �Wi^lI�PS �. � ��272' � Z IICENSED CONTRAC10R5 DECIARATION /1 � d� . �iC. w��SG 4/+ss NO. Wclt.UNITS I hereby offirm�hat I am licensed under provislons of Chopter 9 aD�RE55 VI N��.0 ��R�P (commenting wiih$ection 7000)of Diviston 3 of�he Business and pl �� � _ LIC• �6� S�a Professions Code,ond my Iicense is in full forca and effed. dTY �1 'o�- �� CLAS aK, p�. - VALIDATION 50.FT. NO.OF NO.OF CNECK License Number ��� .CIos�6��/� SIZE - STORIES FAMILIES� - ONE � . . � J� VALUATION DESCRIPTIONOFWORK ,_+CA2/iII I N� � � Controdor oie ❑ f f 060 .❑I om e:empt under Sec. � �0.�' S yR jj 6 3��r ADD O , yt / AITFR H.BP.C.for fhis reaion ... . G1� 1^1 eY��1 1�141N 5 NP� E7AIR ❑ .s � - �1 4 5 7 A USE OF D a oo�e: exisTwc e�oc. f �n � Y�. • • •2 3 ... $ign0lVfe . �' AP�PRI TT h C/ « O. �� �2, FINAL 1 OWNER-BUILDfR DECIARATION �ATf I �� - I • �2�O O I hereby affirm�ha1 I am exempl irom the Contrac�or's license " � pDDRE55 i 8��� e6 S�a�.kf�C/� 95'X b 8" FINAL ��- � Law for the foliowing reason(Section 7031.5,Business and e • • •2��Q� � Pro(esslons Code): � �� �- �� P E EN - y . ❑ euuoiN� 1,a:awner of the prope�ty,o�my emplcyees with nDORE55 I o 9.0 8—8 8 woges os their sola compensation,will do tha work ond ��p,�ITV � rhe srroctore is not iNended or oifered far sole(Sedion TE` ! ?1 4 5�8 A 7044,Bvsiness and Professfons CodeJ. � �pNT ACTOR � 1,os owner of fhe property,am e.cl�sively can�mcting N�� ' �' • ' ' ' � with licensed[oMracton fo Constrotf tha projeU(Sec- -� ADORE55 � tion 7044,B�siness and Professions Coda). � • •J�,Jr� , REOUIRED YAR� HWY fOTA1 SESBACK � CONSTRUCiION LENDING AGENCY - SET eACK PROP.LINE WIDTH w : .3 p,5 0� I here6y afiirm thal Ihere is a construUion landing agency(or � FRONT Ihe performance of tha work for which ihis permit is iss�ad P.l. (Set.3097,e��.e.�. s�oe . 0 9.0 8—8 8 P.l. lendei s Nome ^A W lOM4 Ref,N _ . . F.C.Fee S �d Permii Fee ' Landei s Address \(� I certify thW I hava read thie opplication and state Ihm the . . . Iseuance Fee \V IDMA PIG If � �� above informaiivn is correct.I ogree fo comply with ail Counry � Invast�gation Fee ordinonces and Stale Inws relafing fo boilding cortstruction, Totol Fee ._ _ IDMA Perm.N. . . . and hereby outhorize rep se 'vas of�hi�Counry�o enter � upon th o ve- nt n, g�y f r inspection pu poses. / �j�y� �,�[/�,[/�,r[/� SFF REVERSE FOR EX�LANATORY tANCUAGE / ignat o}ApPlicanl or Agent . � Da�e . .. . . . \ . �'�\ ` 2 � a o <;- _ � S c � m _� �� � o r � „ro o c o S n , �" ��° �m o = `�,i D � � .-... C o m � � -�C �m' - � 'F O n p , '�O Q '�._ � p� 'i� O . ' .r,.{. � . .,., �C . . j C ''w (1 7 , •� �3 �� �.= . T � � � � . '� 7 �7 . Q .ip ' t.7 "'O r m Q. Pv j �. _ y . ' � � P�O , p O ?" 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