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WORKERS'COMPENSATION DECLAkA710N - - � . -
. . . ..,.. .. . . . . . . . . . � ...� ' .. .. . . . _
-I hereby afFirm thai I hove a certifimte of consent to self P f/� yF�1R y■' (y�� P �/■�■r7�■f'
. ., . .. . . .. _..._.. .
insure,or a certifimte of Workers'Compensation Inswance, �■ ����/a��o „■ o� .Yu,'`�I�V �■ ��lt\■ ■
o�a certifed copy thereof(Sec.3800,La6.C.) � �`�
61WETX�qp COUNTY OF LOS ANGELES BUILDING AND SAFETY
. PolicyNo. Ld�pany Hartfnrrl Grniin - -
� Ce�tified copy is hereby fumished. FOR APPLICANT TO FILL IN' eu��o�rvc� �. �.
ADDRE55
� Cerlified mpy�is filed with the counry building inspeo- ��� gUI�DING p�
tion deparfinent. AODRESS ��] �
Da1e V'" -SJ� Applicant C�TV ZIG LOCALITY
� CERTIFICATE Of EXEMPTION fROM WORKERS'�� � - ND.OF BtDGS. NEARES7 . ��
COMP�NSATION INSURANCE - SIZE OF LO7 NOW ON lOi CRQ55 5T.
(This secfion need not be completed if the permit is for ane � �,j ASSESSOR �� � -
.hundred dollars($100)or less.) TRACT 42568 �e�ocK LOT NO. MAP BOOK PAGE PARCEL
TEL. US ZONE MP.P /
1 certify thar in the perfarmance af rhe work for wh'ic6 this OwNER No. _ �J�� NO. I`!"�� y
permit is issued,I shall not employ any person in any mdnner r! SPECIAL b
sv as fo become subje[t to fhe Workers'Compensation Laws. P.DDRESS �✓7'fl CON�ITIONS �
u
Date AppliCanf � GTY COSt M ZIP p�
!�`TICE TO�APPLICANT: If, after makin this Certificofe of ARCHITECTOR TEL. DISTRICT GROUP TVPE FtRE PROCESSEDBY o
9 ENGINEER Aram Bas NO. F
.npfion, you should become subject io 1he Workers' - J COI� _=ONE �
(.ompensotion provisions of the La6or Code,you m�st fohh- qDDRE55 3990 Westerl P�, l d�- �3 � � a
wifh comply with such provisions or this permil sholl be � - �
deemed revoked. �TE�� STATISiICAL CL4551FICATION APT. CONDO.
CONTRACTOR NO. _ L.�
LICENSED CONTRACTORS DECLARATION - . �i�. CLn55 NO. � DwEu.UNITS�L
I here6y offirm ihat I am licensed under provisions of Chopfer 9 A�DRE55 NO.
(mmmencing with Section 7000)of Division 3 of rhe Business and _ , , ��� SEWER MAP �
Protessions Code,and my license is in full force and effecL CITY CL455 -�BK� "� - - VALIDJI IQN_
nnnc , 5�.Fl. NO.Of NO.Of, CNECK �%� J A.
Litense Number y��.]Q Lic.Class � SIZE STORIES FAMIlIES ONE _
L� VALUATION }; a n e_a�j
CaMractar Date ❑ESCRI ION�F WORK ''� A D a ; 1�[� �/�y v+ r J ^y V�<
T
�I om exempt under Sea S 7 n � F q�7ER � , L� -
u�Si.'J GG:J-
B.&P.C.for fhis reason Ne REPAIR � s
USE OF � C`d.L i;"v C
D fe: EXISTING BLDG. �EMOL
Signature /�' �l� APPLICANT TEL. FINAL
NER-BUILDER DECLARATION � PRINT7 NO. - DATE �v"F-'✓'
I hereby af£irm that I am exempt from ihe Comractor's License .
Low for the followin reason Section 7031.5, Business ond ADDRE55 FINAL
Professions Code): 9 ( ' " PRE ENT � BY /��i`^�� �C������
„art^� BUILDING .. ��
�, as owner of ihe properiy, or my employees wifh ADDRE55 1'r��' s � ° �'�. -
wages as their sole compensation,will do ihe work and
the structure is not intended or offered for sole(Sec7ion LOCAUTV , � ,,�,ta�r,v
7044,Business and Professions Code). MOVING iEL. - ' � � _ ""
� I,as owner of}he o ert am exclusivel confractin COMRACTOR NO. - , � ,.,,` . 4 L,c,� '�_
P� P Y, Y 9 .��.GU u
with licensed coniranors to cons}ruct fhe project(Seo- qDDRE55 �
tion 7044,Business and Professions Code). u�,�u��E,
CONSiRUCTION LENDING AGENCY�" --- REQUIRE� 707AL SE7BACK RO EXIST.
SET BACK �ARD HWY pROP.UNE 'NIDTH
I hereby affirm fhat there is a consiruction lending agency for FROM �
the performance of ihe work for which this permit is issued P.L � � � ` � . �
(Sec.3D97,Civ.C.)_ SiDE � � �
P.L
Lender's Name Toronto Doini nion�Bank
^� '7�V 7.,y�� LDMA Re4.#
144 Sansome St., Suite 700 P_G.Fee$ +< - .�r Permi�Fee �i �•r ,
- Lender's Address (�
I certlfy that I have read ihis�app icaTi�or;a state haf ihe ��� Issoance Fee �O^-f��v LDMA P,'C R
a6ove information is correct.I agree 1a comply wilh all County Imestigarion Fae �.�-�-�j
ordinances and Sta�e laws relating to 6uilding consirut�ion, Toial Fee Ll O GT�yT'' iDMA Perm.p
and hereby authorize representptives of ihis County Io enter
� upon 1�a6ove-mentioned property far inspection purposes. f '
a 79���({-^ SEE kEVERSE FOR EXPLANATORY LANGUAGE �-J
s
_s�i'=�
Sgnolure of Applicant or Agenf Dote .. . . - ... ..' .. . . .. ..... ... . ...._. . - ...." . . . . . ...���
PLANS TO APPLICANT INSPECTOR'S NOTES OS5`VGR-BUiLDF.R DECI,ARA770N
, ,... . I hereby affirm tho�i am exempi from the Coniracror's
To: Relurned License Law for the following reason. ;Sec. 7031_51
Approved 13usiness and Pmfessions CaJe:Any city or tounty ie�hicG
No. Dafe No. Date . � reguires u permit tu construct,ulter,improve,demolisG,
�� .� � � .. ,....._ _..rYrepair anp structure,prinr to its issuance,also regueres
. � tbe applicant for sutb permrt to file a signed statement
. . tbat be rs licensed pursuant 1n the pronisionr qf iGe Cnn-
-.
tru��tor's I.icense Luu:(Cl upter 9)(ommencing uitb Sec-
- - tion 7000J of Uivixion 3 oj tJ e Business attd Prnfessions
CodeJ nr that 5e is exen�pt iberefrom ax�t tbe basis for the
afleged c.cempaiox.Ax,y i�infation ojSectiox?031.5 hy
Req�ired Da}e Received �����ppr«an�for a pe+,.:ie subjecas tho apple�anr r�,�r:,�i1
Approvals o�pPProved .pett�lty nf v�n6 rnore tbav+(ive GundreJ dullar.r(SSOOJ.J:
Yes No
!] f,as owner of the property,or my employees with
Wofer Certificme �� �- � � � � - wages as their sole compensation,will do:he work,and
the struct�re is not intended or offered for sale(Sec.7044�
Healih Department . .,. , , . � . /iusixess¢nd Pr�fessinns�Gule:The Coxhactor's I.icense
Lau�does not apply zn un ou•ner r f propert��u:bn builds
Fire Deparimem - or improv�es tJ ereon,and who does su��h irark 1 iinselJor
. through his num employees, prorided ihat sucl �-�
Grading . - _ , prnvemenls are nnt intended or offered/or safa
- � - . .. ,_ ., -� bowe:•er,the fiuildin,e orimproven:entlssold u�ithin one
Geological . � ' year nf compTetron, Lbe owner-builder uvld hare t/>e
� burrlen r j prn2�ing tb¢t he did nnt fiurld or imqrove for
Pedestrian Protection _ tbe purpose nf saleJ.
(Fence)(Canopy) � , � � - �-��- � � � �.asownerof�theproperty,omexdusi�elycontrao
'ing with hcensed conirocfors to construct ihe project(Sec.
Special Inspection � - 70441 Susiness and�Prrf ssi�ns CoJe: The Contructrr's
fConc�(Masonry)(Welding) � � � - � � . � License l,au•dnes nrri applV to ax mm�er nf/�rn(ierty wl�o
� - burld.e nr improves lherenn,urtd u�fio contrarti fnr su�b
Lof�rainoge � � �� prnJects uilb a c�ntracanr(s) l;cense�l purs�.axt to the
Corotractor:s l.icenm I,au+/.
Porking . . _,_:. .. _......, . .� ,. . . . .
-. -._ , :.. _. . .. P_ .
_. I om exem t under Sec ,B.&P.C.for this
reason
Dafe Own
Approvals Date Inspecfor's SignaTure � � � - . � � INSPECTOR'S NOTES
Lomlion— . . .._., ..,,.,. .: .._,.�, _
�Se�back&Vards) ��� /� �
FOUII(IP1i0�5 ���
Slab ��"b l� (< F. .. � .. ,. .
�' �G
Frame ,/U.� . . . . . . . . . . .
Ene�gy Insulation .�16,G.� �
LathiDrywall- �7 — . . . .. " .. .
Interior J���a�
Lath—Exterior �r b.��7 ) . . . . _ . . . . _ ': . . - .
House Num6er___ - - . ... .�.: .-.._ . .:. . _.........._ �. -
Correct 8 Posted � �
Fillq�- . ' '
Enfer on Front
Rc�t= � / � . . . . . .
ty7's—SS-�.s �/�r-t—' �l.l'7.�--�