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0770A (4)
WORKERS'COMPENSATION DECLARATION I , i � . . �. {� �- I hereby affirm rhaf I have a certificate of conseM ro self � � � � �� � insure,oracertifica�eofWorkers�omPa�,a��o���,�,a��e, �i ; . APPLtCATION���F..OR=���BUILDING PERMIT-.� �. � ls ...-��; or a certified-ceFy theraof(Sec.3800,lob.C.) COUNTY OF LOS ANGELES,. BUILDING AND SAFETY ' ' ' Policy�'o.�7Company f�+.�.-r..-..r,�r. � � . . . _.. � . . . BUILDING � Cenified copy is hereby furn�shed.f�IQ�Q'�Q22..,� FOR APPLICANT TO FILL IN ' aooaess' � ' � Certified copy is filed with the county building inspeo- � eURDING �., - - , , , � tion depa�tment. I n�ORE55 ,Z G. -rj O[ALIN. .- NEAREST . Date ('S�1Rr4"L� Appli n � � • CrtY ' LP � . � CROSS ST. � ... � CERTIFICATE OF EXEMPTIO RO ORKERS' I �� NO,OF BLDGS.':� ;� ASSESSOR � � COMPENSATIO $URANCE SRE OF l0T NOW ON LOT' � / �P B�K PAGE PARCEI ' (This settion need not be c pleled if the permit is for one ' -' USE ZOnIE MnP . - hundred doilors(5100)or 55.) . TRACT BLOCK �� lOT NO. i")'��� .� NO. . �. . . .TEI. . . . . . � . SPFCIAL . � 7-�� I certify thol in 1he performonce of the work for whith this '; �NE � NO. -' � �Q CONDITIONS 4.'�,., , . .. . . ...._..._.,. .. . .... Oi TRICT GROUP TYPE FIRE PROCESSED BY O permil Is issued,I shall not employ an n in ony manner � �I � � � CONST Z � V ' � so as to become sub�ect to the W rs'Co pen I n�DaESS � � _ ; .. . _ . . 10 _ �) c � �. Dot�w — PP CITY ZIP � + STATISTICALCV.SSIFICATION APT. CONDO. �F l, NOTICE TO APPLICANT: If, aNer�' in is Cartificate of kRCHITEROR TEL. � � � � ' {,/ . .. . ENGINEER . . . . ....__._.. NO... ..... .- nq�NO. DWELL UNITS_ w. �l A li , I 9 �Exempfion, you should beca subjed ro the Workers' d . , Compensation provisions of t La6or Code,you must forth- I' qDDRESS� � SewER MnP � wilh tomply with soch pr isions or this permit sholl be i. VALIDATION �? deemed�evoked � tONTRACTOR ��� - � BK:� - PG, � ' , . LICENSED CONTRACTORS DECLARATION � ��c. � � r � I hereby affirm that l am Iicensed under provisions of Chop�er 9 �� ADDRE55 NO. "VALUATION � , , � � (tommanting wi�h Section 7000)of Divislo0 3 of fha Bosiness and LIC. e� � � � � ' ' � Professions Code,ond my litense is in full force and effect. i GIN CIq55 -• '; E 0� ���� ► � - � - � � "� 50.R. ~ NO.OF NO.OF CHECK � _ . � License Number•'3�Lic.Class� � 512E ' STORiES FAMILIES ONE- - � � ' , . 1 . . .. . .. .. .. . . . N� i ❑ E . � . . ' /�Z/J�ii�]�;71��v-Qei�e� R-/R-l�'G I DESCRIPTIONOF WORK � �� Contmctor �.� � �� ❑I am exempf under Sea � � . + ... � . -... -_ _. .. ADD.�...� . . . � . ' . ' . ALTER� � FINAI. � . .. ' '. � B.BP.C.for this reoson . . . . . . .. ... .._.___._. ._. ' ' . ' . .. � RFPAIR DATE � . . Dote: USE OF DEMOL ❑ -FINAI � � � � � . E%ISTING BLOG. � � gY - SlgnOlule ' � APPIICANT TEL . . OWNER-BUIIDER DECIARATION . �tiNt / , 1 hereby af(irm Ihat I am exempt from 1he Contractar's Licensa • � � . . ., - � • . ; Law for the following reason(Section 7031.5,Business and ADDRESS 7 / �� ♦,--, e�.� ��' -- �����----�� �� ,� , ��.�• Professtons Code): � - - � peE ENT � �� � �� � �� � � ❑ . BWIDING . .. . . . . . � � � �]Z O A� ' . I, as owner of the property, or my employees with ADORE55 � �•- =�� wages as iheirsole compensn��on,will do tha work and � � �' � � .' �� . ihe strocNre is not IMended or of(ared for sale(Sectlon ����TY � � ' � -� ------ ��-� �- �---- � � $�• • � ' ° � 704A,Builness and Profesilons Code�. MOVING TFL. i %. , , � ❑ NTRACTOR NO. 1.� , ^ .I,as owner oF the property,am exclusivaly eoMrading .-.......-.- - - . .. .� ° � I �1.`Z 'rJ� � ' with licensed controctors to conslruct fhe project(Seo- � ����" �t�on 7044;Business and Professions Code). AooeE55 �' ' . • o � 7 G.2 5� � . " REQUIRED TOTAL SETBACK FROM EXIST. • ' � � CONSiRUCTION LENDING AGENCY Set encK YARD NWv pRpp�INE wiorH� --•��.- � � O$.�� s•.�6 . I hereby affirm�hot thera is a conslruUion Ieoding agency for pgoN� .. . . . - �.. _► - - -. � �. '. . ' the per(ormante of the work for which ihis pe�mit is issued D.L i � � . � , � �Set.3097,Civ.C.): � � � SIDE . _,�'. , . . .. . .. . ._ � '� . . . . . . P.t. . . . . , Lender's Nome � . ,� • _ � . .. .. . .._.__. . .- l . . Lander's Address � , P��•Fe°S Perm�t Fee � , . �� � ,. . .1 .� �.._. .--. ....._.._ . . _. . . . . . .. . '. I cenify that I have read this applitotlon and sfale that the �� Iuuanm Fee -. . ' obove information is mrtetl.I ag�ea to comply with oll County Invesuga�ion Fee � � '. ordinonces and$tate laws reloting to bullding constroction, . � � � - -'` -` �'--��-���� �� � � - � ' � �� 6nd y thorize ro r ntatives of this Coumy lo anter Toml Fee� . , ' . . u n th ove- ione er for Inspectfon purposes. � . . . . .. ... . . . ... ........_. . .--. . . . .' . . . ''.;. � , � ' � ����C .� SEE REVERSE FOR E%PUNATOpY IANCl1AGE ._, . . . , ��� � .. '...._.., ..._ _. ._.... Signal 04 Appticanl or AgeM � pole � � � � � �f� � ' ' �.� . . . ... . . .. .,. . . .. � /, �� i�r���� T� � � �v��>��G�� ��- ��� � 7 " (1 S � O 7 T � O N O Q O (la �^ID G�1 'n -� _ � . ,� ~ �7 O O mo ^ c �- �- m � c. mo `� on m2 '° o � a a -,- - : O INm � �� rp' � •3 a-_ F p n � m � a 0 , .^. m Q� `� p � O �+ � o tD � � j � � � r . T �C N O E N � . Q. n� 1 � � _ � " Q� � 10 ,L ..p.. n� � I � I 0 0 3 � � o � N cv � � n � ' "1 � � o �, c_ A � � v, Q' O -G � r, rt: �� . v � 3 O� �.� '� / �� fj �' I � .. t . 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