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1345A 2796A 2797A (7)
. . . . , , . . . . .....__._._ . ._.... _ _.__ _.._.�.__---�--- - --__._._. _. ._ .. _...__ ...----- - --..._ _ ... , . -- . WORKERS'COMPENSATIONDECLARATION , .'%�• "" � • � , � r.':.: ��, . " . ' ' , . . . -'.-�.- -'•'-'-.- . . - - -' � - - . _ ._ ...._ I I�hereby of(�rm thor I have a certifica�e.o(consent to self qpp��CqTION._FORBU�ILDING PERMIT � insure,or o certilicota of Workers'Compensution Insurance, �� -- -------' - . or o cerii ie mpy t ereo ec.3600;Lab.C.) � . . .... .....__. __ � � - • • COUNTY OF LOS ANGELES � BUILDING.AND SAFETY � ..- -.:,, Policy Nm . .:. . ���Company. ., .... . ---- .: . . -- - - - - - - - - - - O Cerrified copy is hereby fumished.., • FOR APPLICANT TO FILL IN bVILDING r�� Sr .,••,•. ADDRESS `l J � Certified2opy iz(iled with�the coun'ty'6�ilding inspeo ---� BUILDING �` / _� � - � � � � tion depar}men�.' � ' � '• � � " � • AODRESS � 7• (�.�7V � � ., - : ..'.-. .., ... � . ,..,....- �, .._ _ . __ _. _ •-.:: . ..__... / /���... _ __. ' . . Dole ' ... °,.ApplicoM-� CI1Y (�•A • l.v • ZIP LOCAUTY W . . . .. .. �.. . ... , . , . ..; � , .. ._.. ______.__ NO:OF BL�GS.. . . ,. NEAREST._.. .......�__.._"_:_._ _..__._-_..."'..'_".._._ � CERTIFICATE OF EXEMPTION fROM WORKERS' SiZE OF LOT 33`1 �I 3 S�F NOW ON LpT � � . - • � - COMPENSATION INSURANCE � � CROSS ST.� � (This sedion need not be compleled if the permit is forone . .. -- � ----------------- ---'----- ----- -.. ------ �� � ASSESSOR..• ' '- , .... _..� . hundred dollars(5100)or less.) �.. , . . , , TRAQ BLOCK• LOT NO. MAP BOOK - � - � PAGE PARCEL� . � . ,i, . ....�. . � . . ..,. __._' OWNER - USE ZONE MAP TEl„ ' I certify fha�in the pmformance of��he work for which ihis- � �' a ' � � � , �• • / 3 Z ' �y I permit is issued,i sholl noi employ ony person in any manner 2 �/�� �,� ��:: -�- -�- SPECIAL�- ---- - ----- �� -- - • �-� a -..__.. A�DRESS-I�VI_ ._�TiWr_- so os to becoma subjed to the Workers Compensation Laws. /+� )��, - � � � -O re � � '. ':Applimm. . .. �, �. . � �.,, ...... C�TY__..lxf�rl7L:'9 _.. . ZIP__... D._ D� �' .__..._.___CONDIT N5. � . . _ _ _ .�...__ ,V io � ARCHITECT OR TEL. ' �ISTRICT__. GROUP�TYPE_• � FIRE... PROCEbSED BY.. 'Q TICE TO APPLICANT: If,.afler makmg�Ihi:�Certificate of �j��//1 �R►z'{�, 5`T5- o/ �''- cor,ST; �- - zoNe ./ . ,� I Exemp�ion; yoo should become iu6�ect to'�fhe-Workers' �-�- � ENGwEER NO. (p o Compensorion provtsions of the lobor Code,you musf forth- aooRESS'J(p(p L �`�J L�(J. �_. � ��W wilh�comply.with such provisions or�.this permil shall be -- .- �� ���� �� �� �3 �n�� v�'i � TE�. O STATISTICAlQA551FICATION`- APT. NDp. Z deemedrevoked. � ...�„' ' � � � � - _ . r.Y.� .�., ...',.,. ....., CONTRACTON ` • NO. UCENSED CONTRACTORS DECIARATION� � '� �"- - �- - --- �---- - �-- �-liC-�-j M55 ni0. Z-DtveLL UNITS . � I hereby affirm tha�I am licensed under provisions of Chapter 9 nDORE55 O� -NO. 0�� Z^ - �yy�R hM1AP , � (mmmencing wilh Section 7000)of Division 3 of ihe Bvsiness and ___ ... _.. . ..1A. _ _ /�- LIC.---LL-�--� � � � Professions Code,and my license is in full forca and effecf. pTY Y�ww1li�� ��.,.,CLA55 LJ �--� -- �• - -- -- --- ---�.-' .,.� . . . , ... _ _ --. � ,! /._.�. . � . . . � , ., SQ.FT. ., NO.OF _. NO.OF_._�_. CHECK �. � BK. PG. � ...�` . � Y�1F� Li' � • •�{ SIZE � STORIES � FAMILIES ONE ' �l °' license Number 7 lic Clau - , . - • ;.,. . �. • . , .•. . .. L .:..VALUATION � _. . ; .. . . , � -'-- —_ . .. ��z� �� 7 ..._ DESCRIPTION OF WORK - ti�.� - ' "'�-""-"" Contrattor . � ' Dote � � " . +/ .. A p��Q . s��� � � � ' : ❑I am exempt under Set. . . .. .-- - � VGI�e'N - V: "7-- .� -- ----?� 3(�,�j.({ . . � �� � r. ' . ... ,. .., .,. ALTER ,� . 8.$P.�.f0��hi3 reason � � . . REPAIR,_� ..•..S'�Qp� _ _. � .-- . ' f. --._. tJ• �• +2 3 _ _ • use oc � �/�/'�y� � �v.+a � � ' i : , .. ' EXISTINGBLDG. LL'U� UT�(<-v/ --._�..--...'�I"•-��5��,90 � ; .. --�Si�nCture .. .-"�" � APPIICANT p ) 1 ���,/ TEL/t� � . . . , 9 . P�tiNtl l, ELIIYUI' C�IN�. NO.✓l5��o��op; FINAL �v���i� z . OWNER-BUILDE DECLARATIO ._,_ .. . . . �--DATE-�- v -'- ----�---��-��--•-• 1 E.-1..9 D�� : -I hereby aFfirm�hat 1 am ezempt fram tha Co t�actor's License , � 7� ��/ , , � ' ADDRE55 i�� ��1^ (J � rs"t/1� ..,. . ;�. �nw for tha follawing reason(Settion 7031. ,Business ond:� FINAI�"��' ' �'� �' �� �' �Z�2,'�j�=��G � j ___.. essions-Code):.. _ _.... �..'-'- _. ..- ;-._.. . Pe N ' ; 0y ....� � BWLDING • � '____ � .I, as owner.o(ihe property, or my employees with ADDRE55 � � �- - � �i�� � ' -- � � . _. . ... .. . ... .'" "_' _ ".. woges os iheii sole compensation,will do tha work and � i •6� ' �Z79 the sirutture is not intended o�o(fered for sale(Section ��'��TY �. #.• • • •�3 704a,Bosiness ond Professions Code).... . ._.. ._ . .__ MOVING._.-�--�---_.�_. .---------- -�-��-7Et.-�--�--.. ....-- - --- -... . . .. .._ ._ .: � CONTRACTOR NO. ' � '^� � �. 1,as owner of tha properly,am evdusively mMracting � � � � • •9 Q 9 5' � ` wirh licensed conrracrors to�construc�the-project(Seo- ..-- -� - -----. _.____ -._ __._..----.-_ ..... ... .. . :. --.- ---.- - --... .---.. _ ... . ._. A�DRESS , •9 Q 9 5.�-: tian 7044,Business and Professions Code). .� ` . � � • _-' -._- ---.. . .REOUIRED_ .. IOIALSETBACK __ .. i � . � �CONSTRUCTION�IENDING AGENCY � �� ��� � SET BACK � YARD�� �HWY pROP.LINE WIDTH � I hereby affirm that thera is a construclion lending agenty for FRON� 0�'`��'8 7 -tha performance of the work-far which this permit�is�issved -�-- - -�P.t:- -- --- -.. -_---_---------'-'-- -- --: -� ----'----��--'._.. ......... ... ... _ (Sec.3097,e��.e.�. sioe ._�2.7�9,7 A. :.. "".. P.L... . . . _.._.....__.. _.__' _ . '_._ ..;'. ._' ' ___' " _ ' ' _ .._ . ._ . _ ..'__.._ . ." _'_ __ _." __'.... . . � ._ _ Lender's Name , �• . �,�: .5 . ,� � �-• • :� - - -_ . _ _ . _ v.e.Fee s- �g U v<,m�r Fee-- .3vZ�r LDMA Ref.M , , .ti� ` I •.3 3 1..5 0 --- ,. lender's Address 1� ' � - �; -I certiiy4hal 1 hove reod this oppliealion and.stote thaf the ........_ ._..-. --.-'.-.- (/.- �- bevonce Fee'-- '- - �i IDMA a/C k-- '-----� -� �- '� -� -�-_.'._��3-�.�:5 Q�+..: obove information is wrrect.I ogree to mmply wiih oll CouMy Inves+�gm�on Fee " " � _ordinances d Smte.laws relo�in to_buildin construction, _ 3,f �I : ��.3�'8 7 �'; 9 9 .. _.._ .'.___. . __"__�'___'_ To�al Fee_.. � - . ..LDMA Perm:M- and her a i or representati es of this County to enter � ����� �� � �� �� � � ��� � �� � �� � up e bo e-ment e pro riy(or inspection pvrposes, .._ ._ .. ... ... .... ....._. .. ..,. _..._.-.._...---'------------- ----._.__..-___---- ------------ --'-�--- ----- -- —._._._._._.. SFE REVERSE FOR EXPIANATORY IANGUAGE ' � i� ___--_.SignatureofApplim rAgent_._..__.____.Daie-.. '._.___.._._.___'_ _. . _.._.__.._ ._-'_..___...___. _____ ._._'.___ -______.. . _.__._._.... �..__. ..._'' . ..._.. .. _'_...QO� ` o 0 .. � .. T '� t.p ... � �ni " �� G1 p lm �1 -p' � O t �. .p = p� �N O� a 'O 1,4 �^ 'O p n,. . O 7 �. �%, �. � Q 'O �='^ "9 - . � O n p Q O' 3 O :O .` W r '.' ? p � . n' � ; ' .. q � t�+ O cNo� . ' t0'� 7 �u�'. 7t'^p ?. N m ...� , r' m. T • o c . 'a'°. y � ,°o o'°- o;o ' ; . > r .�� � O .Q 'Q,- p p �p N p�:: 'O c0 . , � x � K,-� C�= p ` '�p'� m °. �F � :�; ' D O - ..�. . .. , .. . .� > > O L 7 �� ,� p� 4� � i° . .,s� � � . . O 0 �° �m in ^< 7 ,� '� �°. r- . . . . 9 �� v,Z '� °a o _°"." ~ " o. � , .c p �r •;° � 3 0 ; ^" M a �� � � � � �� t� •Q � 3. ce ; ' _ - g o- .�+ o. " - � • ' o a �.. ° . � . � o � � • � � ;' ,p . - ' ,� � o » �., . 0 9 � l . , - .- b O `, , V . . � . �O n.? . O • •7 ,� . . . . . 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