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10_17_1988 - 2016 PEACEFULL HILLS RD
� WORKER$'COMPENSATION DECIARATION � ��� �- � ��-� ��`�� � -���` � � �-��� _... ..�. .. . - . . . . -. . �hereby offiim thot I hove a certificate o���a�=e�,��e 5e�� � - --- � ---AP�PLICATION��FOR- BUILDING PERMIT . nsv�e,o�o cerrificate of Workers'Compensa�ion Insurance, � or a cer�ii�ed copy rhereof(Sec.3800,lob.G) - . COUNTY OF LOS ANGELES � BUILDING AND 5 FETY Policy No. � � Company . � Ce�tified copy is hereby iurnished. FOR APPLICANT TO F1LL IN A�REu O/(� ��� � Certified copy is filed with Ihe county building inspeo- � � BVitDiNG- - - � � - - - fion departme�L . . . . . ADDRE55 ��� C � , / Daie � APPlicanl CItY . ./�..�/J ZIP IOCALITY �' CERTIFICATE OF EXEMPiION FROM WORKER$'. __ . .__. NO.OF BtDGS. _ NFAREST . COMPENSATION INSURANCE . SIZE OF LOT� NOVJ ON LOT �� CROSS 5T. - C (This settion need not be complered if the permit is fo�one . TRACT��S7� � _ ASSE550R - . hundred dotlars(E100)or less.) r, BIOCK �' lOT NO. Mqp gpq( '� PAGE PARQL � iEL. OWNER O s� G /'D .NO.�� -9 USE ZONE � ^ I tertify thot imthe perfo�monce of ihe work for which ihis - - n NO. I ` �d d�.' — permil is issued,I shall not employ any pe�son in any manner qDDkE55 � L GL �S �� I��� SPEC�nI � O so os to becoma su6ject eo the Workers'Compensatian Laws. �� - ^ v ' CONDITIONS � /��/ U Date ApplicaM . .� . �. .. � CITV !i Ll r ZIP �'. .. ' . . . �/�S, 0� ARCHITFCT OR TEL z / NOTICE TO APPLICANT: If, afler making this Certificate oi i � DiSTRICT GROUP iYPE FlRE PROCESSED BY E:2m fiOn, ENGINEER .L NO. ��d�f� p yov sho�ld become subjecf to ihe Workers' _ _ .._ . _ Q z LONS� - -ZON - a Compenzmion provisions of the Labor Code,you must(orth• qDDRE55 O .� � � / � ✓�J � with mmply with such provisions or Ihis perm(t shall ba � deemed revoked. � � ' � �"�- - � TE�•�� _ STATiSTiCAi C7n5SiFl 710N APT. CONDO. z CONTRACTOR F' � �.�p, . LICENSED CONTRACTORS DECLARATION / ���, �QASS NO. � DWELC UNITS � I here6y affirm Ihot 1 om litensed under provisions of Chopler 9 � ADDRESS .L � - � NO- (tommendng w��h Secr�on 7000)of U�v�ston 3 of�he Bus�ness and ��� ,( ��R�P � Professions Code,and my license is in full(orce and effecL � CrtY .� .�/� r � C1p55 J - � � _ BK.- ' �.. __ . VAUDATION • - SQ.FT. NO.OF NO.OF � CMECK . License Numher Lic Class � SIZE� STORIES�� FAMIUES ,- ONE � �vawnnon DESCRIPTION OF WORK �� N� _❑ . s� /�-�'� /1 � - ' °Q�0 1 A Contracror � �Da�e � .. � (J(/ l../ � ADO ❑I am eaempt under Sec. ' ��� ' � � _ ��c.Y _G/ ,� . � s ��. e�3 , - ALTER B.BP.C.for this reoson . ... REPAIR ❑ � _ . . . . ' 1 • a"?�0 G- Dafe: �� USE OF � - y (� DEMOL I . ' • • •C S.U O� � � E%ISTiNG BIDG. � ./YC�j � . Signa�ure .. . . avatva�T�- . ._��f � � ni0. L�`�G � FINAL � �I Q� 7—?? . OWNER-BUILDER DECtARATION - UATE I hereb afRrnt iho�I om e:em �from rhe ContmUor's license q �-�-�-- --- ' ��� - - ^� Law for the fol�owing reason(Section 7031.5,8usiness and . ADORE55 0�- � �� .��r "U ��e �. FlNAL - � � . � . . ProfesslonsCode):...: .... . :.: .. .� - -_�.-.-.-. .....-._. .._ PRE EN . .__ . . _..Ey_ .. .. _ . _._ - -- _ . .. . ._ . .. � _ � I, as Owner of the property, or my employees wifh ADDRE55 � . wages as their sola compensotion,wiil do ihe work and � � - �. �- -- � -- . . . .. .. .. .__ _ _ .�. �� .. the s�ruc�ure is nol imended or oifered for sola(Section LOCAUTv �. 704J,Business and Professions Code)._ .,_ MOVING ...... ..__. . ._. . _ 1FL._. .._ _. __ � ._ . �. . _ . ' � 1,as owner of Ihe properly,om eRcluiively con�rocting CONTRACTOR NO. , . with licensed conhoUors to construct Ihe proietl(Seo- ... qDDRESS �� -� �' -� - -' - ' - -`�/{'✓�����t.y/�v� . . rion 704a.Bosiness ond Professions Code). V� �� � REOUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY . . � 5ET encK- vaRo HWY., pRpp;�INE � WIDTH �D�. C� . . , I hereby af(irm that there is a construction lending agency for Feotvi l �� � � the performence of Ihe work for which this permit is iss�ed V.l, (Sec.3097.Civ.C.). . . . . . . .. SIDE . . P.L. "lender i Name . . ..- . .... -. . . .. .- ^ LDMh Ref.N lende(s Address � - - � -��- P.C.Fee S e�"�• Permit Fee . . _ , . 1 cenify thm 1 have read this applitation and s�afe that the hsuance Fee LDMA P/C M -- � obove informmion is correct�agree to tomply with all Coonty ' Inveseganon Fee � ordinances and Sfote laws relming to building construction, To+al Fee tDMA Perm.M �- and hereby authorize representatives af this County to enter � - - - - � upon the above-mentioned property for Inspectian purposes. _ . . . - --- ... . _ .. . _ _ __... .. .. _.__.._. . . _ �_ . _.--- . ._ . _. .-----.... _ . _ . _ . SEE REVERSE FOR EXPIANATORY IANGUAGE . �. 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