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1042A (5)
WORKERS'COMPENSATION DEQARA110N {� Insurebor�ocertlfca'�aof Worken'�Compenw�ionslnsurancer APPLICATION� FOR BUILDING PERMIT �s or a cenihed copy eheroof(Sec.3800,tob.C.� � COUNTY OF LOS ANGELES BUIIDING AND SAFETY Policy No. COmpony � Certified co Is hereb furnlshed. \ euaDiNG PY Y FOR APPUCANT TO FILL IN �oo�u .2 .�{] � Griified copy is filed wiih�hs counry buildmq fnspec� a���o�� . 36�� ����OG eGd�i �pCwury R tion deportment nooee55 O w .L/• � p q` NEARES� Date Applicant Cttv �Q ��Y `+ {�P• Ziv � �ROSsyt CERTIFICATE OF EXEMPTION FROM WORKERS' NO Oc atOcS. �55[SSOu COMPENSA110N INSURANCE Si2[O�lOi Now pni tpr O71,E �n..,v eopc vwGE 9ARCEL �This»c�ion need not be compleied if the permi��f for one �./� � �� �E �'1P'P hundreddollon�S100)orlass.) iRA�T ,�3{,iS eiO�K� p �Oit�O ' �/ r�q � - � 1 cerlify that In Iha perfwmon<a of�he work for which ihis �WNfa (` 1� A �N f T�p � �"� ���v COn�oinOHS 6}. permit Is aoed,I ahotl nol emplpy on penon in ony monner �If� [ DiSikKi GROUP �rrE FiRE vkOCeSS[D Br O ao as lo e subjecl lo Ihe Workq���Qompenwtion ws. ��RF� � � "'��$0 �Y� CONST�� V � $�� 1Wiiiu � ��r iA��C�O 0�� ca. Z,P e�T� �� R_3 ,� � o Da�e Applitaro 57An5nCAl CUArtKAUON Avi. C �O. � NOTICE O APPLICANT: II, afler mokinq 1 �f te of 4RCNIIICTOR iit. Eaemp�ion, you �hould become s�b�ec� �kers' En�Gin�Fa �O ' auNp DwEIL UNI75 � Compenwtion provisiom of the Lobor Code,you u forlll- AppRE55 SEwea no+v Z with comply wi�h such provisien�or Ihis permi� tholl be �Ei deemed�evoked. ��TRAR� � BK. pG. VAUDATION 110ENSED CONTRACTORS DECLARATION ii�, I heroby aHvm�ha�1 om licensed undm povi�ions of Cfropte�9 AppRE55 No VAlUAT10N (mmmancing wi�h Sectfon 7000)of Division 3 of Me Business and �i�. Profesaions Code,and my licenae is in 1�II Iwce and effect. Ci7v CV,55 � t , 50 ft. NO.Of NO.OF CHECK Liesni+Number UaClass SizE STOr+iES fAMIUfS � Or+[ s 9 Controttor pute DESCRIGTIprypFWpRK ' NfW �/ � ✓ �I om s.empt under Sec. � � �1 G�.2 A ALTER � FINAL B.6P.G.for�his reown ' REv�IR � DATF tt� . � � � � Date: ex siir+�BtoG p j� � 'NI� � , DeMa ❑ �r Al I •2 1 �5� Sc9�a��ro �vRirNrt� 1 � V�`6�111�'Y � �nio j�� � '�'� ••21 J.S Q� OWNER-BUILDER DECU+RATION p� p� p`/�n / n` 1p ► � I hereby aHvm Ihol I am aKempl from the Contracfor i license qpppE55 � �'J a�`W'Gy' 1�O�Ml, P���c o I�F� ��. 0�.��'�5 low lor the foliowinq raason(Seeeion 7031.5,Business and � PropulonsCode): ���rru� C^. '. f=7( BUqDiNG 7Rk ��rJ I, o�owns.01 the poperty,or my�mployaes with ADDeE55 C ' wo9es as�he4 wle comp�nsation,will do Ihs work and i�i�n D .4_1 ��� Ihe ttrvtl�rq la not INended or oHerad for wle(Section /TI r�•• 7W4,Busfness and Profexsiona Code�. MOVING RL � � 1 � � t,as owner of�he propery,am exclusi.ely contracting T°aCroa uo �t l with licensed conlrattoq to conatruct the projeCl(Seo- ADDRE55 �� U /��b �ion 70�,B��iness and Professiona Code). A V+ REOUIRfD TOfAI SETBACK FROM f%i5I /f CONSTRUCTION LENDING ACsENCY $Ff BACK YARD NWY pp�p i�N WiDTM � y�� I hereby affirm Iho��hero b a corotruc�ion lendinq openq for pqpryi / iha perlorman<e of the work for which Ihis permil is issued v! � iSeC.3097.Civ.C.). SipE — -� -�� G��aao cc. °� lendar i Nome q, (n`/� !' p p, Y e LenderiAddroi�_�IO UI� �IM'� ��4�1f �� U���Y �N• °�teef v..mnFss � ��3•��-y� � 1 eenify ehat I have read this appliwtion and sta�s�hat the�T�JG� h,W,�<s c.s � �0'V " S obove I�fwmotion is carxt I oqrsa to comply with ap Counry inw.nqa��o�F« .�-�—y�-� �y� $ wdinoncea and Stote lawf rolohnq lo buildinq tonuruction, Yowt F« `�""V V ��N " �1 ond heroby oothor�xe raprsuntativef of fhi�Counry to emer � upon Ihe obp.��(neMioned pr�Perty for Impecti��� �sps. �lM'U M � SF[REVERSE fOR E)C►UHATO�Y LANGVAG! / � S�q�awr�ol Ap, c n� poi I� � � . . � FLA.J�SO A?"IICO.tiT ' i. � , Ii �:.7:fl S:M�'_ ' . , � O:l:.•.:Z.I;:7LUa;:DI[('I AP.\T101, •. . � F.—�- +-� � .1 hnr��y u;unn i�,.`I or�axr�.��f.�m�iho Contrauor's � To: , Ralurned . ,.}�_ Lcc�n'• La•, k.• ihe }��iow,np�rnn+on. (Sea 1031 S) .� • , �..PFV�o�od ��Q,V,`1Za__ti(UaT.RG_��"��_\T15L�i-Z�h IJuv�r«nvJ/'r„4..��.�.r,,.;:n,���cirv��.m�nrvu�h;d No. Dc".a Ido. 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