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1114A (5)
. . .. , -�----_..------ ___._ .. ......------------- --� -----_.. --- -�-- - --- - ---- ._ __ . ,, WORKERS'COMPENSATION OEPLARATION , _ VY_ ' � � ' '� - '�'. � '' '• ' f hereby�flirm thal I have a terlificate of consent fo telf APPLI�CATION-�-FOR��.�BUILDI NG F�ERMIT ����� ins�re,or a certificaie of Workeri Com ensation Insmance, , or a certiiied copy Ihereof(Se�3800,tob.C.).� � ' � -�--�---"� -- . . . . . __.... . . _ _ --.. . ..----. . � � • �..:. COUNTY OF LOS ANGELES BUILDINCs AND SAFETY �.� ,�! PolicyNo. „PY �o��Y. ,. �.. � .- , � _..._ ...- - - �--. ._ .. _. __ '... .. Q• Ceriified co is here6 furnished. • :�„.'. FOR APPLICANT TO FILL IN BUILDING �7 [r= ADDRESS � / O��Certified'copy is filed with t6e'counly 6uilding in'spec- "� BUIIDING/�?� /��D� nU`� . ''tion deparlment. ' AOORE55 etl G �-s , ,., . . ,. .:`. .�; , -.,.•.::t _.L _ Dote� " ' -AppliConr CITY L/t[(i/ Z�P 7 LOC4tITV ! � � � � CERTIFICATE�OF EXEMPTION FROM WORKERS'� ,-�� -�� � - - ��'� "�--'�� - -����- NO.-oF eto�s:-- -------�. NenResi._. .,_. � - � 512E OF LOT NOW ON LOT : CROSS ST. ...�....."—'� �--'�'-..... .__........._..__�.._-.. � � ' •' COMPENSATION INSURANCE � � '' . ,., . .. . � „_,_ . ...._'..._ . . �� J ASSESSOR.,.. . " ... ..� �_.... ..., .., � (This setlion�need not be compleled if 1he permit is for'one �-�-- TRA BIOCK LOT NO. /�,�qp gppK ° � PAGE� PARGEL hundred dollors(EI00)or less). � .. � -� TEL U 2 NE �P , . . __..._ ... _. . . . .. . I certify�thm in the performanca of the work for whic6 thiz OWNER �NO �� 4 � Z , �a I � � SPEGAL.-..._. ' :: + permit is itsued,I shall nol employ any person in any manner - � � - �� � � 1[� � so as to betome subject to�he Worker o pensation laws. ADDRESS- � -��C'IYZ - -"- �� CONDITIONS � L�l�. '0 . . , . . . - ..,, ' ' I '' �[ ' __. . .._.....' _'__. . _ _ .� .. . � . ., �, "_. .. [ITY..W L !-"__.._ _ZIP_._ 7 _ _ � . .� .- . . . ...._, .'� Dafe � APPlimnt' ' � Q NOTICE TO APPLICANT: If, afler moking Ihi�Ceitificale of ARCHRECT OR T��� , .DISTRIQ._. .GROUP TYPE_i__. .. .FIRE__ ._.PROCESSED BY__ J�,,, I ENGINEER NO. CONST. ZONE �J Eaemption;�you should bxome subject to"�the Workers' -'-�- �.1� f W Compensation provisions of�he labor Code,'you must forth- qDDRE55 � - -� - �:V� �- - 3- - `�-,�� �� with mmply with soth provisions or�ihis permil shall ba � �- � � � � deemed revoked. .. - � � � � tE�• STATISTICAL CV+SS�FICATION , � APT. CONDO.�: ,Z , . .' ...�..� ,� „ ...,• CONTRACTOR ��/ NO - . ._ - . .__..__. ._.... _. . .. ' . '____ __. .._ _ " __ ' " -� I i UCENSEDCONTRACTORSDECLARATION. ��,.',� -- -�--- � -��� ��--� �� � ii�.� - �-�� Cu155NO.�LDWELL UNITS � I hereby offirm thot I am licensed�nder provisions of Chopter 9 A ORE /a(� � NO. � l0 ��R�P , . (tommencing with Sectivn 7000)oi Division 3 of 1he Bosiness ond __.. _.._/�� . . . _.__ _. ..._...UC.-- � � ' ' ' ' � ProFessions Code,and my license is.in foll forte ond effeU. cmL�iA�/7 CtnsS C- � ""-""-'BK-�"""� -"-"�" " . ----VALIDATION--"- - �� . , ; �/. / __ Sq.F7 NO.OF n NO.OF CNE K � � � 'I Li[ense Number .� �iG.C�oss� $IZE STORIES o� FAMILIES � ONE � . ':�� �' . .' � �• _" � ;� .� . � �.. . - DESCRIPfIONOFWORK . �.. . . ... _. ryEy✓. � _..V ._ _.. __ ... . ... -; ALUATION.. __ �o�,.o��o < —�7 /J 0 : I b� 3�'� � ❑I am exemp�under See. . . ... . . . .. ATlI C��.. .C"-.D ��1.('�_ aoo--❑ ,.'_. _ _. ..--- . .._ .i . _ . . ..,. . . .. .. _..,. J i n/ i AUER � ' I � _.�:.. 8.8P.C.(or this reason ..... _ �� J� ��O J� �1 7 RFPniR_Q - S.'.-----�--- -'-- - - -•- -� , � . . .. . ... .... . ... ._ ._.... _ , . ,_ USE OF ; � � ���.LL A I E%ISTING 9LDG. 7 ..rJ �j � Dare:------- - '- oFrna ❑ ' ' ....._!___ _�• '.'.�__.; 1 hereb affirm f , APPLICANT • TEI. .. Signotvre � �- -- ----- - . . .._- .._. ' FlNAL � OWNER-BUILDERDECLARATION _ .._ .PRWTI���(� / N� '7 _.DATE --..-.-'�' '- -' " � y ha�I am exempt from the ConlroUor's license � - " :��I • •-3 6 7'S j ; .._. .,..-� - low for the following�reason�(Section 7031.5,Business and ADDRE L ' FINAL �� -`� " '� � �. . .3`fi 7 5 T _ _ ..... _. . - - - � ..Proiessions Code):. .". - ... . .`... .`-..' .._. . .. PaESENT , " Y - . . - - . . .. ... i � I,as owner of the propeny,_or my employees with nooRE"ss � _ ' 0 A O�'��-�7:.'� ',, _ _ _..... ,------ ---- ---- - - _ --- woges as iheir sole compensation,will do tha work�ond � , � ,� , ; Ihe shutlure is nol inlended or offered for sole(Section LOGLiTY � �- " '704A;Businessand Rofesslons Code).-- - --�--�- - - MOVING��--- --...-..... - - ' = iEt.-- -- . . . - _.. . '. . -- -�� ._. . ' '"' - - . � I,as owner oF Iha properly,am ezclusively contracting CONTRACTOR NO. � ' ` � : � witk Ilcensed�controctors to-construct the projec�(Sec- ._ -.. ._.. _ .. -- -' -' '-' --- '+ '- - - ._. . ._ ._ ._ . -' tion 7044,Business and Prafessions Code). ADDRESS � p d5,( �4 V , � ,_ .._, ,._ REQUIRED_ -_TOTAlSEiBACKFR M._ . I . /�__� . -\_._. _._. .__. ..; -CONSTRUCTION LENDING�AGENCY�" '-�' ' ' � SET BACK �YARD' 'HWY' pROP.uNE WIDTM� (/ D� A�I�' I hereby affirm tha�there is a conshuction lending agency for FRONi 'l � " - • -'Ihe performante of Ihe wo�k for which ihi5 petmit is issued -�-- P.L....- _......_ ._.'_. . ....__.... ...._"""' '... ._! '_'_'_.._.�- .._.____'.'.._;_-____.__ _ _... ._'___ _ -_ ($E[.3097,CIV.C.J. SIDE � ��� _'_"_' V.L._.... ._ . ._. ._._. .. ._. .. _"" __'_ _ __ __'. ___..." __ . ._ .... .._... __.. .. ._.-.__ _. . _'.._ ___._.._...._._ ..__...._._ _ ..._'__. _. ' _ _ ' ' , Lender's Name ; � , .. . LDMA Ref.N � _- . .. . . _ ___... _. .. _.. .._.. ._....._._ __." P.C.FeeS' . ' '__'.._ - PermitPee' ' _ ��•,. _' _ ___ -'-' lender's Address r' ' �� "' ,1 certify that I heve read.this application and slate that 1he ___ �_._ '_ .._. __. Isew�ce Fee. . v--�- .O- LDM4 P/C p-..-. .. �-.. � .- - �'� � �='i obove informarion is correct.I agree to comply with all Counry invesrqat�on fee / � ����- ' ordinances and Stme laws relaHng lo building_mnstroclion, __ ___ ...._..._._____.._...__.._. ._ Torol Fee-�-�K/-'-�S -LOMA-PermrM---- ---- ���� � �.:: _ . . ...._._._.__. ._ _..,.. .. '.'.� . and hereby authorize representatives of this County to enler ' , upon the ab ve-men++v operty for inspeUion urp es. � � �---. . _ - -� - --_ . .. . - '.'--- --".. ... ._..- - . " - -- - '-- -- ----'- . ..-- -'-'._ -..._. .-- _....__ .. -_ � SEE REVERSE FOR EXPIANATORY LANGVAGE - � -�\/SignaNr fA� licanf gent._ _ ....._ _- Date_. � _' _. ___.'_ _ .' 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