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0592A 1321A (4)
f / ( _ - � .' � �...�__�.'__�".."......���. ........_�.......,. • %, �-� WORKERS'COMPENSATION DECLARATION - � ��"'""-"—'--"--------- • � ' ' ' .hereby offirm rhot I have.,o cerr'f�ca�e of consenr�to sell �� "---__... _ - � . ... . -.. .. .- . ... ..... .-. . - .-._ . ...;`.,,, .. +.,. - � . . ... . , �., msLre,ord'certificateofWorkers'Compensoton��5�,o��e, �APPLI�CATIQN���FQR��.BUILDING .PERMIT- or a ce.�+fied coev thereof(Sek 3800.Lob.`C')-�.`'."..,) ' -- . -._ ..-.. .. . _ .... . .__. "' ' COUNTY OF LOS ANGELES � � � Pol' No. 4-� QZQ�Company S�Q'J�'TT/I'�?' " _ ._ BUILDING AND SAFETYS` � •_�,�Q� ' �Certified capy is hereby fumished. ,., FOR APPLICANT TO FILL IN evnowc C � � Certified copy is(ilbd�wifk the mvnty building ins ec- " ADDRESS � � ..., , . ,. P . BUIIDMG O � � OO �-(j. � . �'Ilon depaAmeM:'��"� ' . ADORE55 • , . �.. . . . . . . .� , � ., .; . .i,. '.. . � .' . 'n/�'„ q. -} . � . � .. ApplicanY .. . , � CI7Y �( V!�'Y .'/ ZIP �/ / __. _ �ocaun � , ; - . CERTIFICATE OF EXEMPTION FROM WORKERS'� �''� ` - -�-- --- - - - - � -NO.OF BLDGS. - - �- n�qRESi......__:__..__�_....._ , � - � SIZE OF L07 CROSS SL . _ ..�... _. .. -----.__._. _�_ hundred COMPENSATION INSURANCE � � �;�.'•r NOw ON lOi (This section need not be-compleled if the�permit9s for one -�-�- � -.._.. _ . .__. . � - dollar5IE100)or less.) .. , TRACT BLOCK�...-_. .. ... IOT�NO.....-... .. �ESSOR , .. .. . . , . - .. . , . p I MAP BOOK��� OAGE� VARCEC �, . � ��- OWNER- f'- �-F L LC�UL(�N- TFL Q USE ZONE A1AP I�ertify thm in�the performance�of the�work for which.lhis --N - permit is issued,I shall nol employ any person ia ony manner AD� b /� C �C l •} . so�as to become sob�ecf�o the Workers'�Compensation Lows. �- � �� -t-- -,-�)�-�---- - -- -- _ � � �-- � � � - - �-- � . - .�6 � RESfr� - � � - . SPE IA _ � .� � . , . . . .. . . �r �� . .�. � _' . CONDITIONS .. ... _ V Daie Applimnt �. ; ,. _ .... CITY It G'�'7. . .L7 �U l0 ---- ---""—-- - NOTICE t0 APP[tCANT:7f;'afier mok'ng Ihis Ce�hfica�e af /+RCHiTECTOR ' TFt. � . .�.. � � � E%empliofl�-y0U sho�ld become•su6ject f0'-�hg"-Workers' -���- ENGINEER N� DISTRfR_ GROUP TYPE . _ fIRE PRO�$$EDBY. ��r Compenialion provisiom of fhe LoborCode, you�mus�fortb- ' 'Q � � ;y�� '�.i_�.N� � , :W ADDRE55 NS with comply wi�fi suth provisions or this perm�r.shall be ._._ __ _ �J � deemed revoked., �, ,�.�.� � � �., . .. . ,, ' / n �a.� TE�• - STATiStiC4l CtqSSip TiON �y �' " - _ .. COMRACTOR C '7D t/ �/2qd0. ^ , J . APT. C DO � Z LICENSED CONTRACTORS DECLARATION � � ._.. �1 n +7�p ... _ �.�_ LIC: �S/v0 C1A55 NO. ._ ...__ ".'. . .. .. _ . I hereby affirm�ho�I am licensed under provisions of Chopter 9 qooRESS �vi/,� �I7� NO.q ��tlr UNITS ' (commencing wiih Section 7b00)of Division 3 of�he Business and � �R�P � -: - ---- Professions Code,�and my license is in full force ond effect. ��Ty S 00 " � - - - . . -� ' . IC • :... ..�. . . . , ..., . ,.,. , CL455 �� .. , ex. .. pG.._ ._._ _. . _.VAIIDATION .. . . � ' _ �.�. NO.Of NO.OF CHEOC ,. ., .. : .. . .. ... ' "' ' LicenseNumber ���� O � �.ic.Class� � SIZE �20- STORIES �-� . ,. . , /,, n ... FAMILIES. .. ...ONE- � �� . . .�. . �.71�YI-'[LN�lC� - O�,. �..J� .TEIY�IV� IM�7�{�"_. NEW.._ . VAIUATION .. .. . . �. ... DESCRIPTtONOF WpRK � ----�-- � � .-.. Controctor �^ ry, - -�� . �I am exempl under Sec. � ��� ADO S� `Jv�v . ' '. . --. .. . .�-=-- . . , . _. __ _.__._._.. _.__ _. .. . , ... � z0592A - ..B.BP C.for lhis reeson .. .. � C[«�' � �f/L�1 � � .f}L�L� ALhR � �. � n , ' . . ! "_.. I N �/ I REPAIR..� ..S____.. ._. .,.. .._,. _ _ .. .�• • • •2 ___1 _..___' .._.. _ _' _dote: ' __.�� � ,. USEOF �/'lT '-C' ❑ . , . . ' . . . , _ .�. , ExiSIwG BLOG. 1fGCdU iv (� �cti�a ; � e a 3 g 2 5 ..._Si� -t`rw\ i' . .. ._.. __ . . ..... APPlIG4 - . ... - i % OWNER-BUICDER DEClARA710N PR�N ~ Np FINAL � . � s o v = . -I hare`ayaffirm thot I om ezempt from the Conrroctor'sticense �� - ---"-� �-- �- �- . ��DATE��- - � ' ' _ &z 5'� . ' '. .-_.. , . Law for tha!ollowing�reasan(Setlion 7031 5, Business and A�DRESS � ' A� �� -"' �� L Cf�- FIO6 FINA .,/. , .� j O G� �,.�a 7 'Professioos Code):.' '-�--- -.._.-._..._. __--._-..-. "._ PeeSerlt . � t, as owner of tke properry, or my employees wirh no�RE5�5 BY . ' I woges as�heir sale tompensation,will do�he work and � � � � � _ _.._. _.. - � �� � � ' the:rrocture is not imended or otiered for sale(Seuion lOC.4utY � - -" ""; - , -�- --704d,-Businesz and Professions Code).------ �- --- M04iNG � �-- ��� - ._.._ ___ .__. � TEL- . .. • ��, t ._..._ '.__....._... .._ . . ....... .... " __ _. I I,as owner of the property,am ecdusively contratling COMRACTOR � � • . - - � - �-�with�licensed�controclors�oconstracftheprojecl�(Sec- • ���---�-�--�- - . � � ._ .. _._ ._ _. A�DRESS ......... __...... ,, ' tion 7044,Business and Professions Code). �- -- -�--� ��� � - � � '�- �z ' * REc,UiRED � . iOiAt SEIBACK M_. XI i. ' ' � 1 J� I A �.�'�� -`-- ��-�"��- CONSTRUCfION[ENDING-AGENCY-�----"��- '- - VARD• HWY � SET BACK PR07.LINE WIDTH � - �- --' I hereby affirm Ihat�here is a construc�ion lending agenry for FR�NT , r" " ��' � � ,� �.:-•� -- �iha performance of Ihe work�for which Ihis permil irissved .- "' '-P.l:��--- � "� --- -- - . __.._._.___.. "'.�_ . ' � , �C' � " . ($ec.3097.Civ.C.1• SiDE ._ .._.. . . .... .. _. _ _..._ : � a .�-Jr.S n -. . I m " "_ . ... .. ..._._.__.._. ._....._.__�. ... .. _. P.t. - . . .... . . . �. . � `, lender's Nama �� � � � � � $ , . tDhU Ref.M ._.._ ..... . ''... ...• • • •5a5`0�-- � , . ._ _ _.. . __._...__ _.,.___.. . ._.' P.C.FeeE � lendar's Address ��� � ` P��mn F�e � -� Si I'b- � � , _. �.p Q02 87 .I cerlify thar I.hove�ead�hit applimtion ond state.that the _. .. ' JO � . �. �� . ..._� -.__._._'\ � Isvanm Fee .-_- i � I � obove informotion is mrrect I ag ea to comp�y wi�h all CooNy '�� � �IDMA PiC��-��--.-__ .. ... . . , � _Ordlnances vnd Sfate.lawt relafin to bullding[onslruction, �^�es�goi on Fea - ;� - � , and hereb autharize�e reseNo ves of this Coun fo enter - � �� � � , \ - To�al Fee� ��S �.Q , ' Y P tY _- .LDMA�Perm:N....._ ... . .. . .. . ... _. �_upon the obov - eMi ned pro rty�For inspection purposes, . , , � -�� .� � . ._ _ . .. .._ ._- ___' '. _____ . ._"' -.�... .... � . '�e �_ " _." . ...._._ . .. ___.. _ . .___ . . _ , ..., . . . ..._ .__ SEE REVERSE FOR E%YLANATORY LANGUAGE . � � ..._Signarore of ApPl�mn�o.Ageni _...___�__.._Daie.. _. ._'-_- ' � � � � . _'_ .____.._ '___._'. ' � _ O ..__. . .__ _ .._•_.... . 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