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WORKERS'COAIPENSATIONDECLARATIpN 76M444 . �
�E$,F,2.eo, MISCELLANEOUS APPLICATION
� hereby arttrm tnat � na�e a certifiCate ot consen[to�szli ' COUNTY OF LOS ANGELES [3UILDING AND SAFETY DIVISION
insure,or a certificate of Workers'Compenmtion]nsurence,or �,
a certified copy thereof(Sec.3800,Lab.C.) � �
� Policy No. � Company • FOR APPLICANTTO FILL IN �VILDING (� /�_ /� �
� ❑ wooRess �Z�� J • �� C.4}IJl OY� I�tY
Certified copy is hereby furnished. nu��oiHc �a i v �- 3Re�t UY� �hJ 2 �ocaurv (�R-1�v j—
ADORE59
� Certified copy is filed with the county building inspection . He.aesr y+_ p'm n
department. �oeaurv WhlauT I%FtCp. enosssT. ��p�. ,� .
Date Applicant PIENREST /�_ �;�� {� o�srwi r no. e o� TYPE n reo sEo or
CRO55 ST. L,��) �� � corvsr.�-y��
CIiRTIPICATE OF EXE\SPTION FR01t N'ORKERS� LccAL 1�
� COMPENSATION INSURANCE OESCPIPTION lOT NO. ' BLOCK . III 3� 'o�ww }
3 (CInCLeJ STATE MAJOR SE ONO LOCAL a
no.oF s�ocs, �
(Tliis section necd not be completed if the work involveJ rpaer NOW ON LOT � �+�� E SPECIAL CONCITIONS V
by thc permi[ is Cor one hundred dollars ($100)or Icss.) ,� vse oF � L�
I certif that in the SRE OF LOT �Z'�X �� E%ISTING�LOG. �L��j� ���F `2 v /1- �
y perfarmance of the work for which this U Q
permit is issued.I shatl not employ any�person in any manner OYlHER w•v•C. �e N'�-�Z ' f-
as to become subjett to the}fy� 'ers'C+n9Pe �tlo Laws. Mn�� C+ OCCVPANCY GROUP � w
;� 2_q��� // woowess J�"'M� C
Date �7� ppplicant_A._ q N
NOTICG TO AYNLICANT:If,after maAing this Certificate of urr w(L�t.��JT' ���� 1 no�� .C'3�.1' ���a�� OCCUPANT LOAO z
Exemption, ynu should become subject to the 55'orkers' AppLICATION FOR EXIT HAR�WARE:
Compensation provisions of the LaAor Code,you must forth-
with comply with suCh provisions or this permit shall be {RAILER usc� GEOIOGV INSPECTION No Spee.Knowl. ❑
deemed revoked. �
LICtiNSC•D CONTRACTORS DF.CLARAT[ON OCCVPANCY INSPECTON Panic Devices ❑
I hercby a(firm that[am licensed under provisions of Chapter SAFETY PERMIT� (LIST ITEMS BELOVJ) Ho.ov exirs �
9 (rnmmencing with Section 7000)of Division 3 of the Busi- .1 (�
ness and Professions Code,and my license is in full force and IC-�I V S �l u}.Q m(,(N� `�� PpRKING.
e(fect. ,
SPACES REO�D � PROVIOED
LicenseNumber Lic.Ctass �trv�� � �� �^ '�� LIMITED TIME USE
Contrac[or Date I-��1� UlIrP��I'u IP.NTeV o.rE oerc
� I am exempt from the Iicensing requirements as I am a
licensed urchi[ect or a re6�s[ered D�ofessional engineer SIZE OF '�� Sc (/�.,��� NO.OF INSPECTOR�S
acting in my professional capacity (Seet�on 7051, Bus- ExisnHe 9LO0. 1' 1 r• STORIES I 81GNATURE
inessand I'rofessionsCode). n... ` FINAL APPROVAL
FREBENT USE OF 9UILDING h�Y�.� : p 7 R 4 f,
Lic.or Reg-No. Date
HOh1E 0�1'NEii-BUILDER DCCLARATION NO.OF E%14TING OIIIL�INGS O�E ,
C Lr✓')L� GP �r' . . e .J O
ON LOT ANO llSE � • 4 r�i,J L
I hereby affirm thah f am exemp[ frnm the Contractar'S �
License Law for the following reason (Section 7031.5,Ousi- o�, ��n .-
ness and Yrofessions COQO�: NO.PAnKING � '` ���
SPAGES PPOV�DEO <
� I,as owner of the property,will do the work end the ��.G 7—���!
structure is not intended or offered for sale (Srction � �
70a4,IIusiness and Professions Code). vnovoseo use oF eui�oirve �y�., �� .
CONSTRUC'IIONLI:NDINGAGCNCY �n�^� �U��Ir.1 � >
I hereby affirm that there is a construction lending ugency
for the performance of the work for wh�ch this permit is
issued(Sec.3097,Civ.C.).
Lender's Name ��
PROPOSEO MA%.OCC.
�Lender's Address PERMIT FEE O •'�"' �
t cer[ify tha[ 1 have rrad this application and state Iha[[he . ^ L�
�above information is correct.1 a6ree to comply with all Counry �SSl/ANCE FEE C� )
�ordinanc State law elating lo building COOStlIIC[1011, TOTAL FEE O�l) �
�and h et au honc re rese i a'ves uf is County to enter
J� t b ve r ty for nspection purposes. StiG REVfiRSG FOR EXPLANATORY LANGUAGE -
� �� ��� �
SignaWre of Yermittee Date
. .O�YNGR-BUILDER DECLAP.ATION
- . � � � INSP�CTOR'S NOTES
� - . �_ 1 hcreby afGrm that I am escmpt from thc Contractor's
� Liccnsc I.a�e tor thc toIlmvin,tcason(Seaimi 7031.5,
� ' Busirress and Profesriorzs CoJeJ: Any eiry�or ro�netv ,
' - IPlSPECTOR'S �����iclr reqairrs e penrtif to CO�ittrttct. alter, intprorC,
-APPROVALS�. DATE SIGNATURE .� .. �,- demo7is7�,Ar repCir O/ly StrilCturC,prial fo ifs lSS��C/tM,
TRtat�en USe � clro reqi+r�es thc applitcirt Jor s:iclr pern:it �o file c
' ti,rted statement tho7 he is litcrued pursumtt ta Ore � .
SAFETV PERMIT - . . Proristorrs of(Itc Confraclor's lirerlsc Lcx' /Cl+aptcr 9
. .`, r �, . (commenring wiU� Sertiva '1000/ of D'n�irion J of the
TEMPARARY
STRUCTURE APPFOVED Rusirress aud !'rafessiors CadeJ or IGaf �i�•ir eserirpf
TEMPORARY , flicfCfrnnr errd the bari.e for the e!leged ezcrr�,tion..1nr
STRUCTUFlE REA70VED eiolClion of SCC1i0n 7031.5 6}'unyapplicaru fura perrrir
� � � suLjec�s flre appliranr ta a eiril penalty af rro�rrnre fFtan
- . � fire fnmdred dallers(SSOOJ.:
_ . ❑1,ac m�'ncr of tLc propeety�aill do Ihc«ock,and
. . � , , . .. ., . the structure is not intended or oflrreci for sale. �
FINALAPPROVAL " /See 70d4, Buaiiress and Prafrssio��s Code: Tl:e Con-
�� _ lrccror's Lic;rue.lcx''does no�appl}' ta mr on�ner of �
- - � � p�opertp��cho fiui7ds ar improres drereon.m�d irLo daes •
' � •- _ - surli ivork Itintself prorided tlmt siccl� in:proi�emr��tt
� � . � - are not intended n� offered Jor sa7e. If, hnuerer, tGe
� - building or impro��en;ent is sald �vi7hirr one yeQ� of
� � � ranpletimt, the oivrtcr6uilde� will hare dre burden
' oJ proring tha� ffe drd nar bur7d or imprnec jor die
, � • � purpose of scle.J .
1 am cxemp[imdcr Scc. ,
� , 6&P.C.for this rcason
- . .. � .. . . , .
llatc
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O��ner
INSPECTOR'S NOTES � •
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