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Home My WebLink About1272A � �G ��j;. WOkKERS'COA4PENSAT16N�DECLARATION � ��`� fJ ��-� I hereby affirm rhot I have a certificate of�consent�o self A. PPLICATION � F�R� BUILIDING PERMIT �' I insure,or a certificote of Woikers'CompensaPion Insurance, iJ or o certified mpy thereof�Sec 3800,Lab.G.) � Polic N laSl�E�v�� / COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ y ompany Z��%r7' _ .. ar' v FOR APPLICANT TO FILI IN ADDRPSS // G�7�r/Z�-�— Cerrified co is hereb furnished. � Certified copy.-rs filed with the county ilding inspeo- BUIiDiNG , / tion depar mEnt. ADDRE55 �1�50 �/�J/ 8� �//aB-�('J�f`j ��-L Date [ 1 A ' CITV Lti,Y4 ZIP LOCA�ITY�� I�iy-� CE TIF ATE EXE ON F WORKERS' �1 � / NO.OF BLDGS. � NEARE57 COM TION I URANCE 512E OF tOi `� X(� NOW ON l0T CROSS SL ,� � (This secfion need nof be campleted i4 1he parmit is for one TRACT �'j, ty BIOCK LOT NO. � A�ESSOR ✓ hundred dollors($100)or less.) MAP BOOK PAGE PAR(FL TEL USE ZONE NOP � �[ } I cenity ihaf�in the performanre of ihe work for which this OWNER �(. C. NO. rl �fl L- soermit is issued,I shall not em lo an erson in an manner 1 �' '� SPECIAL y as ta bemme subject�o the WorkersPCompensat on Laws. AooRESS �f C.�.g.�'J�! �e�G Z.�(!{J-d CONDIilONS � CITY�LA�(, nJ'� ��.• ZIP V Dpte Applicom � NOTICE TO APPLICANT: If, after makin this Certificofe ot ARCHI7EC7 OR A rr .,,c TE�. DIS7RIC� GROUP TYPE FIRE PROCESSED BV O 9 ENGMEER ivv��iL... NO. CONST. ZONE � Exemption, you should become subject to the Workers' ��/'� . Compensalion provisions of the Labor Code,you must forth- qpDRE55 � r(, �Je- l- � � wifh comply with such provisions or fhis permiY shall be TEI. STATISTICAL CL4551FICATION APT. CON�O: � deemed revqke[l. CONTRACTO� NO. '� / � UCENSED CONTRACTORS�ECLARATION r-7� ��,r„ ClASS NO.��WELL.UNI75 � I hereby affirm thot I am licensed under provisions oF Chapter 9 ADDRESS/� S — ✓Ih• N�� 2�` SEWER MAP � (commencing with Section 7000)of�ivision 3 of the 8usiness and �7 ��, Professions Code,and my license is in full force ond effeci. CiTV p/��-• �' CLA55 �'-�'� VALIDATION /� �J SQ.FT. f� NO,OF NO.OF CNECK BK� �'' License Num6er_d. 2'�' Lic.Class C'^•�'�'� SIZE a. �/ STORIES FAMILIES ONE onlra _ e � � � f�� DESCRIP710NOFWORK (J'�Q/V �C�9 NEW � sA��T120N _�...�`r"'_ � !x J ADD ❑ / �� 2 L C A i am empt under Sec. � ALTER '�'m s. h w ¢ � B.BP.C.for this reason REPAIR ❑ S Date: USE Of --•s�a��a�.C.�j DEMOL ❑ � � fr�l J'C� EXISTING BLDG. Signature_ APPLICANT.--� TEL F!N / f �' �'4'�G�� PRINT)�R O. ^�{7~I '� Y�� OWNER-BUILDER DECLARATION (� DATE .- � A ,y I hereby affirm that I am exempt from Ihe Contrpclor's License qDORESS � s��'�-C/�• ��'� ;i C��1 _�7 Lpw 4or the following reason(Section 7031.5, Business and PIN � Professions Code): p Sy � n � BUIL�ING „ 1, as owner of}he property, or my empicyees with A�DRE55 waqes os their sole compensmion,will do ihe work and �Q�q�ITV ' the structure is nct iniended or offered for sale(Section 7044,Business and Professions Cade). MOVING TEL. � I,as owner o4 fhe proper+y,am exclusively confracting CONTRACTOR NO. wirh licensed contractors to consiruct the projecr(Sec- qpoREu tion 7044,Business and Professions Coda). CONSTRUCTION LENDING AGENCV SETOBACK YARD HWY T�TApROP�LNE�R M WIDTH I here6y affirm ihaf the�e�s a conslruction lending agency for FRONT rhe performance of ihe work for which lhis permit is issved P.�. (Sec.3097,Civ.C.). SIDE P.L. Lendei s Name LDMA Ref.N m P.C.Fee S Permit Fee J.... � ' Lender's Address g I canrf that I have read rhis a lication and state thar the ` c^r; Y PP Issuance Fee ( . � V LDMA P/C# _ obove�nformalion is correct.I ogree to comply with oll County Investigation Fee ordinonces and Srote laws relating to buifding<onstruction, Yo�ol Fee � d a LDMA Perm.N and hereby authorin representatives af ihis CouMy to enter upo�the abova Tione ro for inspecfion purposes. 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