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1461A 4701A 4702A
.v . _ . __ ...__..� .. ;. __<., ._. _._. _ .._.._. _..._ . _ _ _ . _ _ .�_�. _ ,... .__ .. „_ �--_...� ...._._._ _ , y � _ _,. , „, , , � WORKERS'COMPENSATION DECLARATlON"" � �? - _ .... '_ . .... . . ,....... . ..:., . i , . I hereb offirm that I have a certificate of consent to self � insure,or a cerfificate of Workers'Compensafion Insurance, �� � �PPLIC�ATIO�l� FO���-���Ul����ING �PE�R�MIT 1 ' or a certified copy ihereof(Sec.3800;La6.C.) : � � • ,. .- l COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No '� f Company ' ' . . . r � . ���Ce�rfied copy is hereby furnished. �y�?'� ._, ' F�R/aPPLiCl��T T�F�L���1 � -- �' B�ILDING ^+,� ��� � �. --, �..1�,C^� A�DRE55 ,�. h �1.C�f Certified copy is filed.with fha coun}y 6uilding inspe � � BUIIDING '� � tion dePartmen�. - �'��i AD�RE55 G���i` C'cxt7 Sf+��e� L'_�'�=.... '��.V. � . LOCALITY Dote Applicont � �iry�%r=j/S��qJL� !4%�, NEAREST F� ��P CROSS 5T. �'' l�+1(�:,�.L c,� CERTIFICATE OF EXEMP710N FROM WORKER5' �� 51ZE OF LOT�L� 'L.Gt NO.OF BLDGS. ..,C]_ ASSESSOR - �� COMPENSATION INSURANCE� -�� - � ���� - W ON lOT G- MAP BOOK PAGE PARCEL (This section need not be completed i4 ihe permif is for one � �'� �� USE ZONE MAP ��� �,�- hundred dollors($100)or less.) TRACT /�;�} . J�pZ. lOT NO. NO. TEL ' ��^^1 SPECIAL ���y F�J C.i+ I certify that in the performonce of the�work for which ihis OWNER � J CONDITiONS F"'f"!f=F{�„ �� ermit is issued,I shall not em I erson in an ❑nner ' DISTRICT GROUP TYPE FIRE �PROCESSED 9Y �� P P�Y a^Y P Y^' �� CONST. ZON R• o as to become subject to the Workers'Campensafion Laws. ADDRE55 r � cirv �/1%5�-S �:7� ziP ��� �'3 Date App�itdnt t' STATISTICAL CLP.SSIFIC4TION ,- APT. CONDO. �� NOTICE TO APPLICANT: If, after moking this CerFificdte of ARCH�TECTOR�H�,_���- rEL.�"� � Exem fion, ENGINEER 1� C�' � � NO. CLA55 NO. DWELL.,UNITS ,� p you should become subject �o fhe Workers' h ev Compensation provisions of ihe Lobor Code,you must forth-_, , qDDRESS IV U/vM'�YG"�/���'� +��C�. SEWER•MAP � with comply with such provisions or this permit shall be l Gc' 7EL - `"' deemed revoked. � � � CONTRACTOR • NO. BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION ��� �� �teC uC. , . I hereby affirm that I�am licensed�under provisions of Chopter 9 �� ADDRE55 � .ii� T�NO. VbLUAT10N � -� (mmmencing with Seciion 7000)of DiJision 3 of ihe Business and . ���. : - 4 ; � Profeuions Code,and my license is in ful�force�and effect. �,� 'CITV CLASS �$�����.� ' t �- � � 6� ' � � � �.. }� � 54. , NO.��OF.. ...... NO.OF �CHEIX ► � y . . �`�.,'�. License Nomber =���7J � Uc.Class,Y,� SIZE- StORIES � FAMILIES ONE g � , . % ❑ s .27i /h—i) . � ': Cta ; �f�t/�p'�,(„CT'�� Dtlfe � 1 DESCRIPTION OF WORK ���U�C� /�Ct� NEW � Cont�aCtor . . . ADD � ,u ,, ' �. /3f!%E��',J!' t.+ �.'4`� �y�Lr� � �"-,�, �I am exempt under.5ec. - � ,y � � , " . ALTER � FINAL � � v . CJV(��i.. ❑ DATE � Y_ �•�L ,.��._':�,1,� . B.&P.C.for fhis reason „ �' � REPAIR � ' USE OF C�// .�� n . . � ' Date" cXIS71NG BL�G. �� �"� ��lf'Gi'DEMOL Q FINAL � � -� . _' ;. . , ._.. , gY . .. ,.. Si nature APPLICANT .. .TEI�Lf.3 , �� ' � 9 OWNER-BUILDER DECLARATION � � PRIN7�'�R'�-%I����--�'���" NO. � . I hereby aff rm that I am exempf from the CoMratror's License -/T� � /y-`.}'UC�'/LC-vr�(,�E.,, � , � Low for the following reason(Section 7031�:5, Business and AooReSS cvde�l:. C.�}. . Professions Code): PRE � - . - ..� BUILDING I, os owner of the property,or my employees with AD�RESS wages as their sale compensation,�will do�he work ond � _ � the structure is not intended or offered for�sdle(Section -`"- LOCAIiiv ...., ,,.. . . , : , . . . 7044,Business pnd Professions CodeJ. � MOVING tEl. � �` � I,as owner of the properfy,om exdusively conirac�ing CONTRAC70R NO. " . 1 l:.i r. with licensed controdors to consirucf fhe projecl(Sec- �� qDDRESS , . tion7044,Business �nd Professions Code). � � � ��� � � " � {r �a � CONSTRUCTION LENDING AGENCY �� � � - REQUIRED YARD HWY T�TAL SE78ACK FROM EXIST. SET BACK PROP.LINE WIDTH , ' c ,�, ; I hereby affirm that�here s a�construction lending agency for � FRON7 � � the performance�of ihe work,for whmh this permit is,issued - P.L . , (Set.30ff1,Civ.C.)..� � - . � . . SIDE...� . . .. . � . . _ .,,.� — - ' . . . ��P.L ' - . . ' ' •., �/4` _ Lender's Name� . . y ` ��`� � $ Lender's Address - � P.0 FeQ$ �� - Pe�m�r Fee 4 Q_ � � ��� � _.� _ a m .; — r �� ;s F � I certify that I have read this applicafion and state that the Issuance Fee , s _ - � ,� ¢ above information is wrrect.I agree to comply with.oll County Investigation Fee �-� . .�. .. . $ ordinances and State lows relating to building mnstruction, � Toml Fee r , - -, ., _ 9 and here y authorize represen tives of ihis County to enter ��� �/� � upon t bove me ioned o,peAy for inspection purposes. -�-- � , � �"��� � � � � . , , - � � �` ' - , � �` ri � a y' f �'��(.�,r�y.�`� :��y k�.r� jp / � SEE REVERSE FOR EXPLANATORY LANGUAGE , ,, . . .. � �� � �� Sig 1 re of54ppl r or A,,nr " ��l o,r . . . . . .. _ ... . . . . ' � . . .._._ ..__.._. .._ ._:.bs. , .. _..�, . .... . � , . . . _. .�. 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HouseYumS•r_.- � � . ; . . �; -. � . . -- - __ ___ — . . . .. . . ... ... . ��. .. . . n Cc�;ecr 8�o �ad . -.� . . -.- .. _ ..._--__ ...— .� _..- Final _ _ ._.�_...._ . __ _ . _ . . . .... ... . Enter on P en° . � . � ,.. �..._....�-_.�_�__�_� �.�..� . '_=-'___ ,. _ ,'_ _�� -- .. , i �