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1416A
WORKER$'COMPENSATION DECLARATION � �� .- � � - ' � - - � . � � I hereby offirm �hot I hove a cer�ifimte of�o�=e�,�a,e�, � � � � qpp��CATION- FOR BUILDING PERAi11T insvre,or o cenificate of Workeri Compensation Msurance, � - o.o cenil�ed copy rhereoi(Sec.3600,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �PolicyNo. Compony � Certified copy is hereby furnished. FOR APPLICANT i0 FILL IN BUILDING� ,,\ �� n�oaess , 1V � Certi(ied mpy is filed wiih rhe county building inspee- gunDtNG � tion deportmenl. � � � ADORE55 � � (,,� (� �(/�� . Date � APPliconl CiTv {}2. Zia � G LOCAUtt 1 0' CERTIFICATE OF EXEMPTION FROM WORKERS' - -�- NO.OF BLDGS. NFAREST �. � - COMPENSATION INSURANCE SIZE OF LOT NOw ON LOT CRO55 ST.� � � "�� (This section nead no�ba compleled if Iha parmit is for one . ASSESSOR . hundrod dollars(5100)ar les:.) , TRAC7 BLOGK LOT NO. - µqp BOOK ' � VAGE VARCEL 1E1. USE ZONE �P I certify that in the performonce of ihe work for which this �WNER , �� p. � permi�is issued,I shall not empl Y�Qny person In any 9nner 1 SPECiAi. -- so az fo become subject to ih orRers' mpe�li rytaw - AD�RESS � �1 � � CONDITION$ � � 0 �f � ��� CITY � G� 2IP ��� f � V Date � Applican I� ARCHITECTOR TFL. � NOTICE TO APPLICANT: If; affe�akiri tYiis Certificafa of . DISTRICT GROUP TYPE FIRE PROCESSEDBY Q Ezempfion, you should beco su6ject to the Workeri -. ENGINEER P10. � - - �pp�5� ZONE F— Compensalion provistons of the Lobor Code,yo�must forth- qDDRE55 ' � 1 I �• Q�,� W wiih tomply wiih,such provislons or fhis permit shall ba .�1 TE�. deemed revoked. coNt2nCroR ll —Q� NO STATISTICAL CIASSIFICATION APT. CONOp, Qj IICENSE�CONTRACTORS DECLARATION MSS NO.��DWEU.UNITS Z UC. I hereby o4firm Ihol I om licensed under provisions a(Chapter 9 AD�RESS NO. (commencing wilh$ection 7000)of Division 3 0(ihe Business and ��� SEWER fMP Professions Cade,and my Ilcense is fn ful�force ond eNecl. �-- CITY - �� � � QASS � � BK � � . . VAl1DATION - � � SQ.FT. NO.OF NO.OF CHECK licensa N�mber � Lie.Class SRE ' - � STORIE$ FAMILIES ONE . � ��� VALUATION DESCRI7TION OF WORK ( INC N� ❑ � � ConlraUor � � Da�e � � a = � �OQ , ADD ❑t cm axempt under Set. � w-S � D W � Al7Fft � 8.8P.C.fof ihis reoson � S • REPAIR � f � � � _ . . . Da1e: USE OF E%ISTING BLDG. � ! S/�FN DEMOL ❑ Si9nOtVfG ' ' ' APa��'�'NT TF�. - FINAL p OWNER-BUIIDER DECLARATION PR�NT �L{'0� �' . DATE.�`Z��y{? I here6y aifirm that 1 am exemp�from�he Contractor's litensa �� � - - � � Law for the following reoson(Sectian 7031.5,Business and - a�ORE55 FINAL - �� . � P, rofessions Code�: � - - � �- � PeE N . Sy . CfI, as owner of tha properfy, or my employees wilh AD��RESS wages oe�hetr sole comp^n:o!icn,will do thc work and � �p�qt�iv � , �"'1 4 1�C>A � Iha structure is not imended or oifered for sa�e(Settion 7044,Bosiness and Professions Code). MOviNG� . TEL. . . . � �� � � � � � � I,as owner of the property,am extlusively contratting CONTRACTOR NO. wiih licensed contracrors�o construtl the projecf�Sac- - AODRFSS� � " � ��� � I • •3 6 7 5 lion 7044,Business and Professions CadeJ. � - CONSTRUCTION LENDING AGENCY � �SE�BpCK - YARD HWY T�Tp'p OP,IWEf Wio7H - - • • •3 6 7 5� I hereby affirm�hat fhere is o tonstruclion lending ogency for FRONi � the performance of the work for which this permit is issued .v.�, 0 9 O 7—F3 S (Sec.3097,Civ.C.). SiDE P.L. tander's Nome - P.C.Fee S Permi�Fee � � ��Ref.N � lender's Addrees � , - I certify thot I hove reed this opplitation and state thal tha __ �ssuonce Fee �DMA P/C M - ' obove informalfon is correct.I ogrea to comply with oll CovnN inve:rigaiion Fee � ordinances and Stote laws relating to b�ilding tonslruttfon, Total Fee LpMq perm.N ' � ond hereby au horize represc�tatives of�his CodMy to emer - �uporr-� a ��-men� dp'ropert.f Inspec�ion purposes. . / i - � � � ±SEE RfVERSE FOR EXPIANATORY LANGUAGE j , .� / �Signar e af Ap licanr or A§en� � pa�e .. . . " Z � 0 0 ! _. t _ .-.� 2" z � e _�. �- � � � 1 ' cr �^ta n o r iy fl p �9 � 2 O � v S Cl � . ~ �` � � O �^ :O �n � � fs �` , . r m .+ Q O ry� •• O .�- O r�j � j, ��y � ,. 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