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WORKERS'COMPENSATION DECLARATION .- - - . � '
I here6y oHirm that I have a cer��f�coie of�a�,e�,�o,a�F - - �APPLICATION FOR BUILDING PERMIT
ins�ra,or a certi{ico�e of Workers'Compensation Insurance,
� or a ce�nRed copy thereof(See.3800,Lob:C.� - �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company � ..
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUIL�ING �.��.7� •
OADDRE55
Certified copy le filed wlth the counry bullding inspec- eUUDING �'1� /� l (�' .Q I
tlondepartment. - � � AooRE55 L-;7 r, � �I. � I � } ,Q !/.�
Da7e Applicant Cltt \� � �. I1 ��) ZIP �"j ��(i� IOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' � - � 52E OF tOT C X '�7 SSNOW ON�LOTS� � C OSSSST.� �
� COMPENSATION INSURANCE � � �
(This aeclion need nol be campleled if Ihe permit is for one TRACT �7�I k.v BIOCK LOi NO. q - ASSESSOR
hundred dollars(E700�cr less.) A MAF BOOK� 7AGE PARCEt
OWNER �Ht� Y' .� C CLr' i�r'�1T`' 3to �7��� USEZONE MAV J 'r
I certify thal�in the performance of Ihe work for whith lhis I1'n R_� �. / O���'�"�
permit is issued,I shall not employ ony person in any manner ADORESS � . � �� «�( r fil'�[S(- � �ECIAL � —
so as�0 6ecome subject to the Workers'Compensatlon laws. � d CONDITIONS �
j 7 U
. Dme ' Applimnt - CiTv � •�• ZiP I �^S - �
NOTICE TO APPLICANT: If, after moking�this Certificafe of AR[HITEROR TE�� DISTRICT GROUP ttPE � FIRE PROCESSEDBV O
Exemption, you should became�sub�ect to tha Workeri � . ENGINEER NO. / NST. 20NE U
Compensation provisions of the Labar Code,you must for�h- qoDaE55 ` � W
wilh comply with such provisions o� this permit shall be . . n-'
TEI. STATISTICAL CIASSffICATION APT, CONDO. .U7
deemed revoked. � � - CONTRACTOR NO. Z
UCFNSED CONTRACTORS DECIARATION . . . . ._ ... . .. .._ ���. . . _ M55 NO. � °'�'� �DWELL UN�75 � �
i hereby affirm that I am licensed under provisions of Chopler 9 AD�aE55 NO. ��R�P
(commencing wirh Section 7040)of�ivision 3 of ihe Business and ���.
Professions Code,and my license is In full force and effect. CITY M55 BK � - � VALIDATION
� ' SQ.FT. NO.OF NO.OF CHECK
Licensa Num6er � " Lic.Closs � � SIZE - STORIES � � FAMItIES - ONE
� � - ❑ VAtUATION .
CoMraefor � Data DESCRIPTION OF WORK N�
I�h7'� AOD ❑ : o ,
❑I am exempt�nder Sec. � �
AITER
8.8P.C.for lhis reoson ,. REPAIR ❑ - -_ �� 4 fl 3 A
� Dote:�'� USE OF
EXISTING BLDG. DfNa ❑
- Signotoro � � �� APaiG".NT TELtN+ FINAL �• �• • •2 3
OWNER•BUILDERDECLARATION PR��'�T �� � �- I1,I S NO. . 1-2325 DATE
I hereby atfirm thot I am exempl from the Contractor's litanse � � ' •5 4 1 9
law for the following reason(Sectian 7031.5,Businets and ADDRESS FINAL '
Profeseions Code�� � - � By • • •5 4.1 9=
U
BU4DING
� I, os owner ot the proper�y, or my amployees with ADORES$ 0 9 0 9—8�
wagas as their so�e compensalion,will do the work and ���TM , _
the slr�ctvre i�no1 intended or offered for sale(Sectlon
7044,Businees ond Professions Code). � MOVING TEI.
� I,as owner af Iha property,om exclusively contraeting CONiRAttOR NO.
with litensed cantractors to construtl tha pro�etl(Sec• � ADDRESS
tian 7044,B�siness and Piofessions Code).
REQUIRED TOTAL SETBACK
CONSTRUCTION LENDING AGENCY � �T gq�K vaaD Nwv pgOP.LINE wioTH � � �� �
I hereby affirm Ihm thera is a mnslroc�ion lending agency(or FRONi �
the performance o!tha work for which�his permit is isfued . 7.L .
(Sec.3097,Civ.C.). SIDE �
P.l.
lender's Name
L� / IDMA Ref.M �
m Lender's Address � ' - P.C.Fee S � V � / Permi�Fee , .
� 1 terlify Ihot I hava read ihis opplicalion and stale that the . issua�ce Fee LDMA P/G M . ,
_ obove informotion is cortect.1 agree�o comply with oll Counry imesrgm�on fee
'q ordinances and Stata laws relating fo bvilding constrocfion, Toml Fee LOMq ve.m.# �
ond here6y authorizc representolivef o(this County 10 enler
� upan Iha o6ave-meri`tione�d�pr/p/perfy for inspection pv�poses.(%
o �,�(�}{�,.CC /l=j��(,(�,Cd� y—�"'iQ�] SEE REVERSE FOR E%PIANATORY LANGUAGE
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