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1078A 1907A (5)
, - WORKERS'CO�dPEN DECIARATION����LN 1`��"`-`C— ,` ' �muraborafcertifh�' ' rkesr'Com�pensafon;�s�.o�a APPLICATION FOR.�'��1�IL-�ING PERMIT � or a ce�rifi d r of(Set.3800,Lob.C ._ COUNTY OF LOS ANGELES �'y,,,,.✓" BUILD{NG�AND SAFETY PoliryN . Company — .� n� � •. �_ Cernfied copy�s hereby furnished. — � � FOR APPLICANT TO Flll N euuowc }I � .j ADDRE55 � �/'Ceilified copy ie filed wilh Iha toun�y uilding ins ac- � BURDwG tian departmenf. ADDRESS Gt.t�� . O 1 /��'� Dale� Applicant �,� ' �"_7L{�` CITY ZIF IOCAIITY `t w.cv� � CERT�EXEMPTIO FROM WORKERS' V NO.OF BlDGS. NEAREST COMPENSATION WSURANCE � � SIZE OF lOT NOw ON t07 GRO55 5T. (Th saction nead noi be�complelad if tl�e permit i�for one TRAn (�,`d�� �aK LOT NO. �ESSOR hun r dallars(s100)or less.) MAP 800K � PAGE PARCEI TEL. OWNER USE iONE ' MAP ��a �cartify rhat Iha performonce of fhe work for whith this J N�� NO. �� � permit is Issued, oll not employ any person in any manner SPECtAI so as to become svb t�o ihe Workers'Gompensm�on tows. ADoaE55 I CONDITION$ � Date Applic � aiv � r" ziv � V � NOTICE TO APPLICANT: If, after king��hia Cerlificate oi ENG�N�EFR�� NO �(Q DiSTRICT GROUP TY7E fiRE aROCE$SEDeY O Examptian, you should become su 'ecl to the Workers' CO ZONE F- Compensotion provision�of tha lobor e,you mus�forth- poDCESS e{� � N W wilh comply with such provisions or this ermir shall be . • TEL. Q STAiISTICAI CVv551FICATION AVT. CON�O, Ca/1 daemad revokad. coNtanct ^ I z , LICENSEDCONTRACTORSDECLARATION n• ' ��. U MSSNO.�DWELL.UNITS , 1 here6y affirm iho�I am ticansed under provisions of Chapter 9 qDDRE 7, � �r NO. b '� (commencing wirb$action 7000)o(Division 7 of ihe Businese and pn 0 ��� SEWER MAP I Pra(essions Coda,and my Iicense is in full force and aHecA Ott . 1 L� C1a55 " BK � ' VAUDATION 2 .�,1 50.FT��� NO.OF NO.OF CHECK Licensa Number � Lia Clas] SRE STORlES FAMILIES ONE . Controcfo y • 1 a�e � OESGRiPTiON OF WORK N�✓ � SA`^[✓ �a,—.�• � S ADD �� , em 1 under Sac. '` AITER � � . 8.8P.C.for thi raoson •• � � • REPaiR ❑ s � �� Q 7•g n Dot : USE' f � . 1 . _ EXISTING BLDG. ❑ ' ' Signofure APP�F�A 17 • TE� FINAI ] f/I #• • • •2 3 OW ER-BUIIDER CECIAR ION N�' � DATE �? / �,J� ( . � (�[�$Q �1 areby affirm tha I om exempf from th Contractor's l(cense � ' A ��1 9 S: La for the following reoson(SeUion 7091.5,Business and ADoae55 Lll(il FINAL � Proi sions Cada): . ey / p �- • • � �1�J.Jr Q� OBllitOMG �� � � I, s owner of tha prope�iy, or my employaes with aDDRE55 C e V 0 8.2 4—8 8 wo s os rbair sola rompensation,will do the work and ' � , - � the st cWra is nol inlended or affered for sole(Sect(on IOCAIrtY , 70a4,B Inese and Pro(essions CodaJ. G� Tet. � � I,os owne f tha prope�fy,am exclusively contrncting CONrRA NO. with license comracrors fo mnstrvct the prolect(Seo- AooR¢55 � ' tion 7044,Busi ess and Professions Code). ' . REqUIRED IOiAL SEiBACK I CONSTRU ON LENDING AGENCY SET anCK YARD HWv PkOP.IINE WIDT11 1 he�eby afiirm that�here i consrruction lendinq ogency for faONt . - ?� 9 p 7 a the pa�formonce oi iha wor or whith ihis parmil is issued P,l. (Se[.3097,Civ.C.). SIDE . . �• • � • P.l. °� lender's Noma 1 • � �Q 5 n ('� `'.�Q�a. tDMA Rei.X e Lender's Addrcss v.[.F�o f� ,.. V Vermii Fee • � a Q 5(}� � I certify that 1 have reod this opplimtion an i thot Iha _ ismance Fee �,_ I�AnA ViC M � 0 9 2 6—8 g obova informoiion is torretl.I agree to comply with all County Investipoi�on Fee A O , � � ardinences and$tafe lows rebting to building consfrucrian, . Totol Fee �f� LDMA Perm.N an ereby avrhori e represanraiives ot fhie Coun�y to eMar � tha a e- n on`ed ropeny for inspecti pvr oses. - . � ' � ✓� SEE REVERSE FOR E%PLANATORY UNGUAGE , Siqnatura ol Applicont Agent paie r �., -, r� ..,�!-:;. ._ .0 1. �R:�E"� ,�. f ,,,\ r , �—�� �� , . . ,�o,j,�o,�,��3 .. � . , . ;�. :� ' _...__.'.. . . . ._. .. . `. �. . . . -�ouy , . . . ,.,, , . . . pa�sod 8 I�ai�o� . _..._.. . _.___ . /��... . . ._ _ _ __... ._ .. ..,. ._ .' .. ' � � . ..� , ' -�aywnNasnoN /.' , _,. I :",1 , _ �� , . � .,. . , . _... :_ _. ._ ioiiatxg�y�o7 ` ', , . _ �Zz� ,o,��.�, � ,;� .. . _. . . . .... ... . . . . . �� nnAia;4�ol � �''` ' . � � � � .. � �// uono�nsu�A6�au3 . . , . . . .. .. '..... . .�... .. __.. .. .. . ' ! �--�'�'� ,y�i(�(f o,.�o,i _r . - - D a�,s . . . ,. - .. -�-- -r,~ .t. .�__.. _. . . ._ - C L'1 suoiicpunoj i i� r"� �,,f„p-.-.::'r�./ ��� ,i . _� . � /� �4sp�oA 8'I�oq:aSl . . - .. . ... . . . . 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