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1762A 4013A 4014A
� WORKERS'COMPENSATION DECLARATION - - � � � - - - - - � --�- _� . . , ,. . ._ ._ __ .�, . .�.P -�.._..-«..,. , ., . -_�, I hereby aff�irm thot I have a terhfimte of consenl to self -� APPL�I�CATIO{N F01�-�nBiJI�LI�I�VG� PERMIT� insure,or o certificate of Wbrkers'Compensation_Ins�rance, � . or�a-cer�i4ied mpy�hereo4(Sec:�3800,tob.�C.) � -� -- . . � - COUNTY OF LOS ANGELES-��� - -.�� BUICDING AND�SAF'ETY�-��� � - lala3z—A_ r7ission .. .,. ,.:.... , -, � �. : - _. __ . , . >. P�olicy No. Company . .. . . .._. BUILDING �^_. ,.... .. �. Certified copy is hereby furnished: FOR APPLICANT TO fILL IN a�ooee5s .�5.>.� � /.�J �f/��T C']_.Certified co�sy is filed with Ihe touniy bUilding inspec- BUILDING � � �i.,/ �X�` tion depprtment. ADDRESS � .ZSSS DdIJ COUi"'t LOCALITY Date 3/19�R4 .ApPlicam ('_�naRnaa�.. ._ . arv Rowland�Hei hts ziP ca°'ossssr.� '-� �/C�i��i t��'. CERTIFIfATE OF EXEMPTION FROFA WORKERS' NO.OF BLDGS. _�_ nS$ESSOR . . - pqGE PARCEL - �- COMPENSATION INSURANCE � ��� � - " SIZE OF-LOT NOW ON LOT MAP BOOK - (This section need not 6e completed-if ifie permit is far one US Of�E - -MAP . �/�/��,1�- hundred dollo[5 $100 or less. - TRACT 30&93 BLOCK LOT NO. � NO. �,' ( ) ) ��TEI. 11�� SPKIAI �- owNeR Presley of So. Cal. No. 540-0500 ' �� cor�omoNa �l/FFC /y'`� � I certify that i the performance of the work for which this .. DISTRICT G UP TVPE FIRE PROCESSED BV � permit is issued,I shall not employ any persan in any monner ADDRE55 4600 us�Drive CONST. Z E e- sa��as ta become subjet�to the Workers'Compensation Lows. � �� ��._� �- �� sC ciTv N , «r ZIP Date Applicanf �. . . . ... . .. STATISTICALCLASSIFICATION . APT. ONDO. � ARCHITECT OR TE�� ��7 ' � -NOTICE�TO APPLICANT: If, aher making this Certificate of ENGINEER G`�'1dr1GS �S1C��72T NO. — CLASS N0.�..DWELL.UNITS� � ' 4bmpfion; you�should become�su6jecl to the Workers' - ;,� .;ompahsofion provisions of fhe labor Code,yo�mus�fprth- qDDRESS�-O3H CJ1c31 Avea� �YdTl e -SEWER MAP� . . � � with comply with such provisions or ihi.s permit.shall be � � � TE� � ' / ` �j ._. deemed.revoked. . � � CON72nQOk 53IilG� dS OWri2Y IvO. � - BK./�/Pc,,�7a+�` VAUDATION LICENSED CONTRACTORS DECLARATION �� - � - LIC. I hereby affirm-�hat f om licensed�nder provis'ons of Chapter 9 ADDRESS No. 89274 YALUAT,ION� (commencing with Section 7000)of Divisioh 3 of ihe Business and �IC, B-1 § i/7T ,A� Professions Code,and my license is in full force ond effect. CITV . . CLA55 '�"Fi" ► _ uceose r�omber 289274 u�.G�ass - B-1 s°.EFr. 2699 sroR�s 2 Fnnni�Es 1 oNE q/� ;., /�' NEW t7L/ �P!� �: Contratror PYESl2y Of SO. y�� 3�19�H4 _ DESCRIPTIONOF WORK Pr�AN �-42�B .. ADO D 5 � J� �� `���j�2 P,-� -� �I om exempt under Sec. . S le fc�RLl- aL'��'1 ALTER ❑ F�NA� J �S° '-m 'C v � - DATE /�J`�"/r�'-� B.&P.C.for ihis reason REPAIR � ���>�l v 2,fJ J ' � - �Date: U E OF � - � � - DEMOL �� FINAL - ., � . EXISTING BLOG. . By ��j R� 9 a�LL�J C.C:�-J u�� Si nature . . APPLI�P,Ni ... ... LEL . - 9 OWNER-BUILDER DECLARATION � -----� � � PRIN7� � .125 NO. S4O—OSOO ►�,hp•�fjF��/ �S_2�—.v(y �. I hereby affirm thaf I am exempt from!he Controctor's License i' . '��. . � law for the follawing ieason (Sectwn 7031.5, Busin@ss and ADORE55 g��� US I}Y'ZV2 .L"'E Professions Code): � � - P2FSENT .. . � . � � - � - � � BUItDING- � -�'� I, as owner of the propeny, a: my employees with qooRE55 - .' ' -_�U},���., . . .wages as iheir sole compensation,will do�he work and . � . "" � - � � ��-� � }he 5lrucfure is nat iniended or offered for sdle(Seciion IOCALITY .- . � � � - ���� _ � � 7044,Bosiness and Professions Code). � � MOVING TEL _ " � �s c o e 7�j . � I,as owner of the properfy,am exclusively controcting COMRaCi02 NO� . _ m Q _v _ with licensed coMracrors to construct the project{Seo- . . � r "�� ��tion 7044,Business and Professions��Code). � ADORE55 . .. _ -... ._ :_. .. ._..._ . -REQUIRED YARD HWY T�TAL SFfBAIX FROM- EXIST. o � a j;�y��; - CONSTRUCTION lENDING AGENCY��- � � Sei Bncic P20v.u Wio1H - - � �� � - ��� I hereby affirm tFdt lhere is b�consirudion lending agancy tor FRON7�� , � . � - -j.j,.i �7—���f._ - - ihe performance of�he work_for which this permit is�issued P.L� - � � (Sec.��3097,Civ.�C.). ' .-. . SIDE� � - ,c�.J'�,{j,;y � . P.L. : Lender's Nome N�A -. - . . .�r. 3��a � g . . . �f a e e a a�'�-�. . � " . . . P.0 Fee$ /^/�' -_ Perm't Fee I � . � Lendet s Address � - � � ~ ��S—� . -� (��'�,�Q(} - . � I certify that I��hove reod ihis application ond state that ihe - � Issoance Fee � - t above informaTion is rreci.t agree b comply wifh all County Imes�igarion Fee � /���/1 � �"O J ih i;�%���- � o�dinanc and St e ws relofing�o building-mnsiruction, Toml Fee C%� - � and eb auth ize epresentatives af this Coumy ro eater . - ; � �.._�(� upo ih en oned property for inspection purposes � - . �• � - - �3�19�84 SEE REVERSE POR EXPLANATORV LANGUAGE - . . � � . . �.. , . . .. . � : , ' .. Bs �5igna�ure of Ap ' n�or Age�� - � Date � � - ' - >, _ � ,a*rv -..- ._..� .-. , .��:,�, . _:. ,.r�_-. - - - _ _ , _b, � .��. , ....-, -.. .___ ._,._..._., - , . . ; -.� �- _. - � _' ' _ _ _ _..-a=x_ .. .. _ _ _ _ _ �_��-_ .._ �,_...,. ... __ . . ,. __ - .�..,_.._�� . _T � - - °R�J r: A"�i'}.`��&�3'� " '' :" b -.o. .� +�-�.. 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