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0944A 0945A
__ .._ .._ _. . ,..----- ..-- --...---. .. _.� . .._ .. _..... -- - - - 17hereby afhrm��°���e of Worke sr'ComCLARATION � � � -•�- �� ' � ����. �•��� or a certi(ed RK�P�S'COMPENSATION DE ;�i. , , ,, , �. i snre or+o ce�lifi.� � ...� � _. .._. . ' _ .... �.._ _. e°``°°'e�"°'8" qppLICATION--FOR�,BUILDING� PERMIT — � � � pensation Insurance . .thereof(Sec:3800.'La .C.). „ .. , . ._._. _. . _. _... ... . . _ . . .. . - � ---- ---- -- -- �- - .-�---- � ---- - � ` COUNTY OF LOS ANGELES BUItDING AND SAFETY � Polity No�ompony . ' � - ..... -- -- �. a Certi{ied copy is•hereby fum�shed. . � . �, .',, FOR APPLICANT TO FILL IN AD�RESS �� Q� � I aCertified copy�is filed�with Iha' `unty building'inipeo- `�'��� BUiLDiNG /� u -! .:`tlondepartmem.'.:��.'",...'� �,' � . . A�DRESS �� Ch� (7 �C F S f y; ^ . , , -; ', _. .. _ ___ __. _ _ _ .._ ___ ' _ Date:�`,;�Applicanl ✓ CiTY LP � �ppq��ty ��� '� 'CERTIFICATE OF EXEMPTION FROM WORKERS•�.,:.'.� ._ _. ..___. __ ..__._..._-------. No.�OF elDGs.� -- -_.._._ NFAREST__..__:..�....,. ..--' .-. '�----- .__.__._,___.y._.; � � � ••'�COMPENSATIONINSURANCE�.���•.'•�;',�������� SIZEOPtOT NOWONt07 CROSSST. _ This�section Heed not be com leted if the` ermit is for one ��� -� . ....�._ _i ASSES50R ... ���� �- - --� � - �� � 7/ / .,.. � .J10.. . . . .. .. _. . . hundred do�lors(EI00)or less.),. ��. P . TRb.C7 ��/ BLOCK LOT NO. I � l�qqp BOOK � �" PAGE i PARLEL � I Cer1i ... � .. ..;. � '. l 1 -.gb (_ EL. �.�• Lf USE ZONE MAP .. , � ., . . �,� . _ , _ _.__ _._ , -. ty tha��inlhe performance of the work fo�which�this �NER � ' � �. 1)- �,.. permi�is issued.I iFiall not employ ony person in dny manner A � ' -.-. .-. - SPECin��. . .- . . .-...-__._ . _ .... . .�O. ,. ,.. , ,.� , ,. . ,,. ,::.• ..p .on Laws. .._._ ADDRE55� •va I�.. . • ._.. ._-. ., CONDITIONS ' ....�. . . .�O so as to becomebu6'en ro fhe Workers'Com ensafi � � � � , . . � . . .. � ".' ' i . � , �.. . ,.. .._'__ GITY� . �.___._ ZIP . _ .._____ __.-.; __._ _ ._ . _ _, . .. ._ .. . ...____ __ _ .. :pC Do1e'. -. .� ��.�.�',qPPliconf-�P �. � ARCHITECT /' i l �7 �.,,, . ... �O NOiICE TO APPIICANT. If,�after�making 1hiS Certifimle of Y �U DISTRiCT GROUP iYPE �� FIRE PROCESSEDBY 1- ENGINEER . / � S �\ - " "' Eiiemptton,''you should 6ecome�sobjed b'the�Workers' --�-�� p / / CONST.; � . ZONE . �{„� Compensation provisions of�he Labor Code;�you must forth- qooRESS d � O/� fC�'7 ' l,(J : ._.._t�-.- .��1 � d wilh comply wilh suth�provisians or this�perm�l shall 6e .-......_ .. . . . . . . . . . . �� deemed fevOked.., . . ,.�� � � . � TEl ��� STATISTIGAL QASSIFlCATION , APT. CONDO. �. '�Z ""� ' � +'' CONTRACTOR NO. ' . .,„•,, : .� _. _ '._ ' __ � __�' _ '._.._. .. UCENSEDCONTRACTORSDECIARATION�.�� , •, .__._ MSSNO. u.UNfTS � � � ��� ' _. .. . . _. _.. _ .._.._ __ _..__.._. -uc.... . I hereby aifirm that I am licensed under provisions of Chop�er 9 ADORE55 � No. �� (commenting with$ecfion 7000)of Division 3 of fFe Business and _. ��R�P i ' ' ���� � ��1 ___.. . ... . .. .. ..__"_ . ' ............ .. LIC.. _ "'_"" ., i Professions.Code,and my license is in full force and effecl. ��TY � QA55 ---�BK;�---� � � '� � � � � -�� `VALIOATION��-"� � �, � � ��� ��� � � �' r '' ��' '� 50.FT. NO.OF NO.OF CHECK �� License NVmber � ��LiC.Clasi� SRE ����� �� STORIE$�� � �FAMIllES' � ���� � ONE�-' I . , , .� , . . . .,�� � :�^�� • ___VAWATION ., . ... � �a L , 7 DESCRIPTION OF WORK� � Conriactor- N/�'Q'/.�'6A/ ' Da�e� -�'/ LcJ A l/ - --❑0 S /1 ��(�! - 1 I I noo ot . �I am eRempl under Sec. ..... . ,. � ' ___.._- ---- -.._ '----_.._. __... . -.' --- -- -— - _ .- -� � i�.:; ., , .. ..,,.�;..:. , ` /� ALTER � , '�; . .. . . B.&P.C.for thii reason � r ' �� ..__' U Z Y'�' I. REPAIR_� - S .._.._. ._ _ �;__... .,.__..- ... ,. . ._._ . _� .__'_.__. ___.. ._ - - 'Dote:_... ... ... USEOP � �EMOL � : . , � EXISTiNG BLDG ❑ . '. . __.. p Q 9� ...._, -.'_' APPIICANT -1/� �C NO.O�I DL ` Signalure �-._._.. ._-_. _. _ FINAL� ! (�-p ... _. OWNER�BUIIDER DECIARATION PRINT � � ._ _.. . .. . .. ... . . . . .�. - DATE..�_` �� ._..- -'.#.e.w.• •.'Zc3 _ . � I hereby affirm thot I am ezempt irom fhe Contmctors licensa /'� /� �� � ' �, taw for the fallowin �reason Section 7031.5,Business and ADDRE55 D� lS ! .t'� � ' FINAL � ��"" '� ^ � t� ` - � _ ..Professlons Code):_9�.. .....(....___.. . _.__.._._ . .._' aRe Nr --Ey-..� .:. . .. . .. -.._ ._� • ^G�,6 3-.... BUILDING � �.� . ..-- .,� �_ 1,as owner of Ihe property, or my employeee wilh ADDRE55 ' I � ' ' ° •?_7.6�3 c=i wages os fneir dole compensation;�wiil da tne work and � -��� � � '��� � � � � � �� ' � , " � " ' �-" �" � " "` " � Ihe strudure Is not intended or offered for sale(Section ��`��TY � ' Q$,Q���Fj�'] , � - 7044,Business and Professions Code).. - . .. _-.. MOVMG. . ...-.._._.. .. ._.._ _ ......TEI. -... __..__� � . . .. ....... .... �I,as owner of Ihe ro ert am exdusivel tontractin CONTRAROR NO. � �� � � p p Y, Y 9 ; �09U,5A ..with Iicensed comroctors to consirvct the project(Seo --. __._. . . _.. ....._.- _.--._.. _ ...._ .... __._. .� .._.. ._..._ .. .._ ...... . ... _ _ . __ .. . . fion 7044,Business and Professions Coda), aDDBE55 � �,, ��� � � � ' . ..__..._ . .. RE�UIRED . VAR�� NWY .TOTAL SEiBACK XI .._.___'.._ ___._ .__._ . .....__ __._._. ._ _.__'. '.•., � ' CONSTRUCTION LEN�ING AGENCY �� "'� �' �""�"" SET enCK PROP.IINE WIDTH' I hereby affirm that thera is a mnstruction lending agency for peOM � � � °`��4���0 -fha performance o(the work for which this permit is issued - --� �P.L . .-- .. . .-. _.,._ _._______._ .. _......i .._ ..... ___..... .... .._. _..: -. _ .... _ n . (Sec.3D97.Civ.C.). SIDE � � � •u�V a c����� � .' _. P.L . . . . . .... . _... __._.. . . ..: ,... ._.. . � _..__'.. .. . . .........._.... ....._. _� ' Lender's Name Q G� $,7.,�,�.� +� ' lOM4 Ref.M . ` _ .... " '._. ...,. . . . . ..._.. ...,_. . ., _.. P.C.FeeS .. _/ �._. PermlFee �.� � - � � � � . Lendei s Add�ess -- � � " � I ..I cenify thm.l.hove read this opplication and stata ihat the --.. -.--._ -- - _--.._._.. lesuo�ce Fee� �..���... ' ..iDMA v2 N � ' '. � - --.. ._. .._. . ...__... . . .__. __.._�z . . � obova informotion is mrrecf.I agree fo comply wilh all County Invesiiga�ion Fee � ; ordinances and 51a1e laws relating to bvilding consiructivn, ___ Total Fee ��� -LDMA Perm.k � � �'�� _. ..._ ._._ . ... _....... . ... .... .. .. . ....... . .. :.. ...' :... ; !� and h eby aothorize represema�ivei of this County to enler � � upo ih abov -meMionedprop'rtyforinspeclionporposes. .(�31 �G_.� .._ _.. _. _. . .. -_-- . . _ _._.. .._ _. _ -.._. . _..._.. .. . ..._ .. . _.. __. . . . __ __ . . . '� ..... - --._ ._.. . . . . ._ . , / ��a�i SFE PEVERfE FOR FXPLANATORV UNGUAGE . ---� --�Signal ofApplicanlorAgm� -_. __.__.pare.. ..�.__�_..... _. ' ' '....... _ __............. ._ ._.. .'.__ .. .,___. ..- .. ._. _.. . ... ._.. "'_ '.""'_ ..'_ .__._...__"'.:�0� . . ,.. ' . �.;.. '. _" � o +. ..,.. • _ _ , - o v Gl -G�- '±_ .� .o- . i . � - ti ° o�cc ��a o� o ,o � ���o '�_. 1 - r. a , ..� r -n N T �O 7r p � ^. J!H �' .7 'N S ���(� R i m„ ns o o � o o c e � o ,�� �� tO o m� � D' ; - S m 3 cr � �_. � • _ fl o,, v ir, al ' �p p �^ � S \ m. lD p �n j 'O � p �� ' p� . , .3 a ..� ' 9 , o ,,. is � I•' � O `� , a`" �a � 'o � O - o I � ,m, �� � o po I o m o�io�: o.o ;3 3 �1��'c `o I� � 10 ,,' � � yi � ! ��'(� �' � l0 � r .. �C N O � ui -� 7 �.� y. C C � . (� . ..' � '',M.'.., �• . �+ 93 a c � , �1 . o � � o� � � � « >>� �� .:I �� � �'' � �� � D � � � � . i , a� co F _ ,i �� � � i.1 I ' � - � ,o � i o �� O � , �o a � , � __ ��� � ��� � S. 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