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10_28_1982 - 2016 PEACEFUL HILLS RD
WORKERS'COMPENSATION DECLARATION . � I hereby ofF��m,ho�� �a�a a�e�;�;�a,a oF�o�,e��,e se�f . APPLICATION FOR BUILDI NG PERNII� fnsure,or a certifimta of Workers'Compensation Insurance, � or a tertified copy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � , PolicyNo. Com ony BUILDING � Certified co y is hereb furnished. FOR APPLICANT TO FILL IN aooae55 � l � Certif" d c y is filed wi anty buildiag inspec- BUILDiNG tion apa ent. ADDRE55 LOGAtItt I �y NEAREST Da(e` Applitont � CITY Zia O CROSS 5T. - C IFI TE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. ASSESSOR � COMPENSATION INSURANCE SIZE OF LOi NOw ON LO7 MAP BOOK PAGE PARCEL (This settion need not ba compleled if tha permN is for one USE N MAP hund�ed dollars(E100)or lesz.) fRAR BLOCK lOT NO. /A� NO. �� y. - � T�, / / SPECIAI -} I certify that in the performance of the work for whfch this OwNER (js G� O. '�� CONDITIONS d ermil is issued,I 5hall nof em lo an enon in an manne� ���� � ^� ��STRIQ GROUP iY7E FIRE PR ESSED BY '� P P y y P Y ADDRE55 s( CONST.'/ ZONE V _ so as to beeoma svbjed to the Workers'Compensation laws. .� � . •� Gt/ -�aG�/ � � � o Dale ' Applicant - � . CITY . ZIP STATISTICAI CLAS IFICATION APT. NDO.. 1— ARCHRECi OR� �-}..TEL,�p/ .- � '/ ' . V •NOTICE TO APPLICANT: If, after making this Cerlificata'6f ENGNFER`.� /2 [71(J N0.6 E' CL455�N0. V � DWEIL.UNITS�� W �emptlon, you should become�subjecf��fo�the YVorkers' � et �mpensation provisions af the Labor Code,yau mvst Iorth- AD�RE55��D � SEWER MAP . N -�ith comply with such provisions or this permif shall be .� deemed revoked. � . TE�' � g � ,�� YALIOATION - COMRACTOR NO. UCENSED CONTRACTORS D£CtARATION - ii�, /�/y � I hereby aHirm thet I om licensed under provisions of Chapter 9 ADDRESS n70.�J� !o V'O VAWATION (commencing with Setlion 70()0)of Dlvlsion 3 of the 8usiness and �i�, p l����� Pro(etsions Code,and my license is}'�full force and effecl. CITY CW55 �U s / , /��1// �I(I �/ SQ.F7. NO.OF NO.OF CHECK ' UcenseNumber �•� 7� 7rJ lic.Class �� SIZE STORIES FAMIUES ONE � ���C.�GI`Dafe DESCRIPTIWIOF WORK . .. N� � . . � Conhoctar J / ADD � . . ❑I am exempf�nder Sec. 'r / �J�/c ALTER � FINAI T r j O�ri� _ ,.�''� B.BP.C. r this reason G�FLaG `� aEaaiR DATE !'�C�'��J - •.J � � USE F • FINAL �• ' ' '�� - Oata: EXISTING BLDG. - DFJ'Aa ❑ g � -Slgnature APPLICAM TEL. Y �{ y � •�j J�h 6 4 _ O ER-BUIIDER DECIARATI N PRiNT NO. ,STj/. - �J�c�i.C3�. .•.•3 J 11.6��s I hereby affirm lhaf 1 am axempt from the Comrector's License . ' , Law for tha following reason(Secfion 7031.5,Business and AD�RE55 � � � Q Rofessions Code): vee5eN7 � � � I Q�H—"2. _ _ . ..__. . . ._' _ ._ _ .__ . .- 9111LDING - _... . . . . . .. . .. ._ . _._____.. -'______ - �- f, as owner of the properry, or my employeas with- ADDRESS - -- � - � � S j 9����� , � • ` wages as their sole compensation,will do the work and � � - J fhe structure is not fMended or affered for mle(Sec�ion ��'��TY 7044,Business and Professions CodaJ. MOVING TEt. - �• • • • '� � 1,as owner of the property,am exclusively contmcting NTRACfOR NO. � � .5��G� .." with Ifcensed coniracton fo constru[f tha project(Sec- ADDRE55 � - � - � Iion 7044,Buslness and Professions Code). . , � � " � � REOUBED TOTAI SETBACK FROM EXISL . •5�T;1.�:n-` . CONSTRUCTION IENDING AGENCY SEi BnCK YAkD HWY pROP.LINE WI�TH � I hareby aifirm that the�e is a mn:tructlon lending agency for FRONr � - � �� � (},Q�—Q? � tha performance of the work for which fhis permit is issued �P.L. , � � - � ,- (Sec.3097.Civ.C.). SIDE , _ � � � P.L. Lander's Nama / � � � Landei s Address P.C.Fee E 3� y� PamN Fee �/O .�� , � I ceriify that I have read this opplication and state that the - luuonce Fee �� +S � � obove information ia mrrecL 1 agrea lo comply with all CounN invesrigor�on Fea ��{-�r�h rdirmnces and State laws relating to building consKuction, Tarel F�e `�l`--3 �� ' � ond �eby aolhorize representatives of�his Covnty o eMer , n bo e-memloned property for nspecy � s. - � - � � � ` SiE REVERSE FOR EXPLANATORY LANGUAGE ot Dot � . . . �� . � �° o � . 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