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Home My WebLink About1488A 2189A i . __ „� WORKERS'COMPENSATION DECLARATION . �� ,heYeby affirm that I have o certifitale of consenf fo self AP�'LICATI4N FOR BUILDING PERNIIT ��insure,or a cerfifimte of Workers'Compensotion Insuronce, or a certified copy thereof�Sec.3800,Lab.C.) COUNTY OF LOS ANGE�ES � BUILDING AND SAF.ETY � Policy No. � Company . . � - � Cartified copy is hereby.fu�nished. FOR APPIICANT TO PILL IN BUILDING 7y ADDRESS I/IS �J � Carlified copy is filed with the coonty building inspeo- � euILDING .�JI � � �y fion deparlmenL � � ADDRE55 ( I P� � ¢'� ��L /� � Date � APPlicant � . � . � aiv p+c Ziv 91 xr`�. . toCauir � � CERTIFICATE OF EXEMPTION FROM WORKERS� - � � � � � NO.OF B�DGS. �� NEq¢ESi . . /"�e'�N� . �( ,�� . . . COMPENSATION INSURANCE �� . SIZE OF LOT NOW ON LOT r7 CRpSS ST. �iL d-i.x..C..� (THis secfion need not be completod if Ihe permit is for one � TRnCT �� BtOCK � - �pT Nq, / �SSOR � � . � hundred dollan($100)or less.) (�' MAP BOOK PAGE PARCEL � �'« CG(J CVI�.... NO. R��r� USEZONE 1JJ�P � OWNER �� I certify that�in The performance of Ihe work for which this NO. : � � } permit is issoed,I sholl not employ any person in any manner ( / "� SPECIAL � � �� - - 6 so as io become subject io Ihe Workers' o pensation� ADDRE55 �7 �� - � ~4v CONDITIONS � V Dote ^��Applicant -C-i UTY ZIP. . . . . .. . . . . p� NOTICE TO APPLICAfYT:�If, after making �s�Certificate of ARCHRecT OR TE�. DISTRICT OUP IYPE _ FIRE PROCESSED BY .�O Exemptian, you shauld become su6jet to Ihe Workers' - ENGINEER �� Cp ST. ZONE [� Campensalion provisions of Ihe La6or Code,you must forth- qpDRE55 �a - d with�comply with such pravisions or ihis permit shotl 6e .- . . � �- � `� . �� V� deemed revoked. �� _'�fG6c�3 SiATISnCAL tA551FICATION APT. CONDO. Z CONiRACTOR � Np, .,}� . '— UCENSED CONTRACTORS DECLARATION �. . . g� t��._... '`� ��CLA55 NO.�DWEII.UNITS � I hereby affirm ihat I om licensed under provisions of Chapter 9 AD�RE55 � � 1 V NO. .bt'�S (mmmencirg with$ection 7000)of Division 3 of the Business ond . . L��, �1 . SE'NFR NU`P Professions Code,and my license is in full force and eHect CITY -. ClASS l.�� - BK � � � . � VALIDATION � � �f p e"L , /�—g SGI.FT' NO.OF , NO.OF CHECK � � � Licensa Number uOn V Lic.Class �' � SIZE �OO STORIES FAMILIES �� ONE . , , � . - �/ p�� vawnnoru Contractor , 't'�Dote � �GZ l f & ! DESCRIP710N Of WORK �J}Q,,LYV NEW �� s / � ` � � � � ' ,- . . 1 �h M ADD a-Zr0 , '�. �I am exempt u er Sec. � �� - - � - � ALTFR B.&P.C.for ihis reason . REPAiR � s .. . . . .`.'.��L 8 8 A Date: ' USE OF . � .. EXISTING BI�G. DEMa ❑ fi�• • • o L�. - SignaNre � . . . . � APPLICANT iEL. FINAL OWNER-BUItDER DECLARATION PRWT NO. ppTE y 9/•�_ � � �d,�i�U� � �hereby affirm thot I am exempt from the Contractor's License � � -�� U L� Low for ihe fo�lawing reason(Section 7031.5,BuSinass and ADDRESS FINAL � <:�.'}:-� � a o��,Q�r � �Prafessions Code): - �� - � g � Ey �f�,(t � - - � " � , ❑ .. BUIlA1NG . . . ��7.� � -R 7 . I, oa ownar of Ihe property, or my employees with AD�RESS !� wages as Iheir sole compenwtion,will do Ibe wark and - �� - , � .- � �� Ihe shucture is not infended or offered for sale(Sec�ion �OCAUTY � � � _ . �� 7044,Business and Professions Code). � � � MOVING �� - � � TEL �� -� - -- � I,os owner of Ihe property,am exclusively confracfing CONTRACiOR NQ . �-with licensed contratfors ta cans}ruct ihe project(Sec- ADDRE55 � }ion 7044,Business and Professions Code). - � - � CONSTRUCTION LEN�ING AGENCY - � � RS�i gACK YARO Hwv TOtApgOP UNE wioiti � - � �� 9 N - I hereby affirm that ihere is a tonstruUion lending agency for FRONT � tt e o . � � !he performonce of rhe work for which this permit is issued � P.L. � �- . (Sec 3097,Civ.C.). SI�E � I �� 3C.50 P.L. � lender's Name . . .. .. . . . .. .. � n.�G�_. g �7 LDMA Ref.M , . - P.C.Poe S ✓J~i� Permit Fea - Lender's Address �� 'y � �(.4�.�c 1� � I cerrify that I hnve read this application and s�ate that the . � Icsuance Fee ��•.�� DMA PiC M � � � �� ¢ above informafion is mrrect.I agree to mmply with all County Investigoiian Fea �\ . � ordinances and Sta�e laws ralating�o building constroction, � ioral Fee ��•J� � �p,yw verm.M � � � � � � i, and hereb authorize represemotives of this County to enter . '� upon the bovewmentio ed �oparty for inspection purposes. � �—�-�7 SEE REVERSE FOR EXPIANATORY IANGVAGE a -�� igna of Applicont or Agam - � pata. . . . �.. . . . . . ..- '��