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1634A 1635A
WORKERS'COMPENSATIONDEPLARATION ,, ._._ �._....._ .. . r ' . -.,,1 ._........_ .."-'..,.'..-" '-'.-'...._ . . .; ..__ ^ .._.. ...._......... ... _ _.__.. �nsuraborafcer�ifcaieofWorkero''Com ensatonlnsuro�self . � � . . .._...._ . _.. _. . ... .. _. .. ..-"--. , .... ..., � .. l, . .�_....._ � . -nt' . __ .. �,1 Y � �. . a��e APPLICATION FOIt��BUILDING PERMIT Y � eof Sec.3800 Lo6 C. � .� . .. . �._._. ._._._. .. , . . . ... . � ' � or a cerfi ie copy 1 er �y,.� },[ti,lt�,� COUNTY OF LOS ANGELES I BUILDING AND SAFETY Pol¢� ' (GV m�ny.�` � rl.. _" __�.__ ' , . Certffied co �is hereb furnished � n � �.� eVIIOWG�i �' �l � av' Y FOR APPLICANT TO FILL IN / ADDRESS G^��� /. VV �` � ,Certifled cop�`is'filed w ' o�nty� Id ng'inspec- ' - gunoiN�,���-�1_ �if...�.r_ f , , -' .�tion eparl nl:��- •1 �T �. C/Cil�fV i i .. ,..1.,, ..� � " ' � p-,.�.-' � � ...� �' .� . .. __'__ ' _ _' . .... _ — . . LOCALITY ; t D'ate .COMPENSATION INSURANCE �� �ITV�h`M�T� � LP �I��'JS � ' � ' � "C.RTIFICATE OF EXE/J�PTION FROM WORKER : �"� "- -' ��- � -�—'---'--�""--�NO.OF eloGS. -- ------� �� nEAREST� _ ' � �' 1'!-�, IimM . ,, ,,,. ,., SRE OF l0T NOW ON LOT + CRO55 5T... � � O�f\ � _�_ _ _ (This�seUion�neednotbe�completediftha�pei itisfor ne •--�- -� ASSESSOR, '-•-� ---"r �'-^•'�' .._..__-'.____"_ _ . _.._.._....._. __'____..__ . hundred dollars(5100)orJess.) , � TRACT BLOCK l0T NO. MqP BOOK'��" . a i° PAGE� PARCEL �1 certif fhat in the erformante o, ., � OWNER���a •�Q"������NO.�� USE ZONE MAP � � � � ... .. - r' �........ AD�RESS_._.._._.._. _..."'____... ..__'_'""_._'_"_.._"'. I- .."_' CONDITION$ � I . . �f fha worP for w�icfi this �`�O. . ......-'- - ..... ...... .... . .� ' �. . Y, P permit is issued,1 shall hol employ eny person in ony monner SPECIA����- 1 a � so a:to b�ecoma su6'ec�'to the Workers Com ensatio�laws. � 'v �� .��. �,,.� PP �. . �.., .- .. ' � AIRCHITECTOR. _....._'.'. ___"_...._ZIP..7EL.'__'....._ __._'__.__- _'_.____. _____I__..__.._. .._. . . .. I NOTICE�TO�APPLICANT��Iff�ofter�makin this�CeAi(icote of ENGwEER Np , .oi5rei�T__ Geoua � � �., i •, 9 . , • ... TVPE. ... FIRE .PROCESSED BY . ..j� I Eaemprion,'you should bemma subject���o''iF18'�'Wofk@f5' '-- CONSL� ZONE� �W Compensallon provlslons of ihe labor Code,you must forth- . � ` � � ADDRE55 � : ..�,a.. ...... ... ..\\ . .:d with comply�with'soth�provisions or,lhis permit shall be �--�- �w � deemed revaked.,, �., . , ..�,�..'.,,,.,'. , , COMRACTOR� � TE�' � STATISTICAL CLA551 CA ION i '� APT. CON�O:• � �;Z � �.�.�,��� � . ...�. . � � LICENSEDCDNTRACTORSDECU3RATION �- ����� ��� � � �-� - � , � _ �q'I O. ..- --- - - _; +�.t ��-�-.�.�� - ��. CLASSNO. DWELL UNITS ( •.,g , ' ..�., . SQ.FT. NO.OF .-'-. NO.OF LIC.....' �HECK , SEWER MAP • i VALIDATIO ��i �P ofess o�nsnCod h ond mycl�ice�rne tDs�in�futl3fo ce aBd eH s'and ..._ _ C ryRE.,y����� ��� �_• ����-,�-� .... .... _.... ._._. . . ._�. ._... !. ._. . �N_. . _ ; ��i�«i , .. . . .. . . .. .. I BK. PG. : . � Q�'�F1�.. � Gi}� - License Number � Lia Closs SIZE STORIES FAMILIES �� ONE � . , . , , ,.. , . .�...�T1'�� ���.VAWATION.....:. � --- . .._.. C, � '� Z �'._ DESCRIPTIONOFWORK_.. .___ _._.-.-__.-_ .__._.._' NEW--'❑ :S� ` ..��� . �.;� ,;, oMroc�or '�� Date , � � � � . . . ADD .._.. ._. ..__.._ �I am exempt under Sea ' i-- - .'-"- --'-'-'_.. ._.._. ...----��---��--�-�---'--'-� . .... , � . ,.. .,.�.� ALTER i ,� .' . �.i B.BP.C.forthisreason .. .... � REPAIR..� .�5.._..... ...._ :_. .. . ...____.-'.__ .. _...., __. ._....__. � ; .,.........._ . . ,...... . ... ._. . ___ ,.., .. USEOF ,��.�� � ��, : I .'_'I . ...Dote: EXiSTitdG BLDG. fint�� � DEMOL .._.__....__..____:'_.__.__..-I .. . . .. APPLICANT 1 ',�� TEL � . -'.'--Signalure -- -_. _._. ...__.- ___-' __��."' .. . 'FINAL ' � . 7RINT �r{.K/ NO. � � OWNER-BUILDER DECLARATION -----. _ .. ._. _.._.--. --. -' .. .._--_.'--- -- ..:DATE��-']'��i`-.._. . � _.__ ....�..- - �.t hereby affirm thal.l am exempt from the Contractor's License �� �-���� ' � Low(or tha following reoson.(Sedion 7031.5,Business and ADDRESS '�,FiNAI •�'� � �� ' ""`' � ' �''� "Prof¢SSIOn5 COdeJ:_._.. ... ........_. .._..,.. ...._..__..�...._ ._._.."' PRESENT . j dy..._� ..._.. . " _' '.... ..� : . BUILDING ,J .... .:,.,.,`. �,.. . .,�i , � I, as owner of Ihe property, or my employees with ADDRE55 1 �, � ���(���j,Q A''� '�� ,•,^^�•c•their=cls temper.sa!ion,will do tFe:vcrk cr.d . . . . ._� .. . � . q _� I,ah'I e�nsedfmntrParoperly,canstrocf thal�o�'Y Se9 _'". COCAtRACTOR '_. .__. ...._".'._._.._.....NO. -.._ . .._ ...." " ' .. _ ..I . __ . . -_'TM ��49.�2 5�I '� _ 7044,�Bosiness and Profesvons Code. MOVING TEL:���� � � - � . '_ .'_ . t ' ' ''_. . . _... . I � Iion 7044,Business and Professions Code)P � � ( � ADDRESS , � �� � � F,� � ..REOUIRED iOiAL SETBAIX FR � . ; • 4 9•2�� .__...' YAR� �HWY. " I._ _._ � ���CONSTRUCTIONLENDINGAGENCY"� "�'-� seTenCK � Pzor.uNE wioiH " � �-�'�`- '--"" -- ""� � -�'� - I hereby affirm that there is a consrruction lending agency For ' pRONT ' � I 0 7�2 4—8 5�; ..the perfo.mance of the work for�which this-permi�-is issved �...-- . p.t. ......- --. . .. .. . .. ....-....._.__.. ...-. -.-. - - -._..._. .. _ .. .. _.._ .. .._.--_ . . (Sec.3097,Civ.C.). SIDE i �1 6•�'S A , P.L. � � ___".__._.__ ._ . _.-_.. _.._ .'____._'___.."._ � _ ' . . �_ . . . _ _._.-__._ '_"__..'. '."_._ Lender's Nome...._. .. ._ ._. .1-- ---.�,. '_.�. •• .. ..... � � IDMA Ref.# I . �..-2 a�. � .._ _.. _. . _ .. . ._ .._ .._.... _.. _... ._. P.C.-FeeS.- . � '.-_ PermilFee_____ _:_. . _l . i. lender's Address ...__.. . l Q.S� � r.� �.7�Q�1��. � i I certify ihat I ve ead.this.applicalion.and.slale.that tha . .'__.___"'._.-,.�___ Iseuance Feo-- � �LDNJt PiC N- . . . �.... . .' obove i cesYan � at laPs�relating to bv ding�co Yltrvct onY:_._-.. �nveirigmmn Fee-----_--_--... Torol Fee-.--_ ..-1. . : -lDkw Perm.M-- -�--�- '-. _. _.... .. ' . 7 8 5.F.i . • • her b�au h nz re resen�oiives of this Count to enrer '�'7 2 4 . I �u n� obov • en n d pro erry for Inspetlio purpo s. � � � . _... _ . . _ ... __ .... � � \ ' � �S, _ . -- _ _ _ ._ i _ ,. _ _ __... _ ' SFE REVERSE FOR EXPLANATORV LANGUAGE i t_.'_ ignorurc of Ap 1ia m Agenl -._ __...'_'..Date. __._.. �.._ ....'"._.._ ... _.... ._..'_' .,...._' ' __._...._.i_.. __.__. __.....__.. __._... _"'.._' '. _._ _. ._.._ .,(�j� � . ' � a .,;- !. � _:�. c c , ". ' „n� � 1_9. -' � � ci `F• ,_ ` -y. 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