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0618A (4)
. . . . . . WORKERS'COM7ENSATION DECLARATION . �� ' � —,�Y affirm lhot I have a�e�,��;�a�e of�o�5e�,�o s��f APPLICATION FOR BUILDING PERMIT insuro,or a certificate of Warkeri Compensation Insurance, or o cerrfied copy thereof�Sec.3Boo,lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ColicyNo. Compony � Certified wpy is here6y furnished: FOR APPLICANT TO Flll IN BUIIDING 's� S � ���J� AD�RF55 � Certified copy is liled wilh ihe counly buildiny inspea � - BURDING C (..1 lion deporfinent.� ADDRE55 � J� �Ti(�J Do1e APPlicant � UTv D � 2iP � � tOCAliiv � CERTIFICATE OF EXEMPTION FROM WORKERS' �� � NO.OF BLDGS.� - NEAREST . . � . _ . �COMPENSATION INSURANCE � � 5¢E OF lOi NOW ON lOT I GRO55 ST. (This setlion need not ba completed i(fhe permit Is for one - 7RACf [._/� A�F�R hundred dollars�E100)or less.) � B�aK LOT NO. MAG 800K� PAGE PARCEL `E`. �o �t9 I tertify thaf�in ihe pe�formance of the work(or which this OWNER �-- O� NO. — U N �P permil is is:ued,I hall not employ ony person in any manner .. A�DRE55 � /� ���,,,/� �ECIAI � � so os Io be ome s hject to 1ha Wor 'Com ensation Lows. -� � � dW CONDITIONS 0 --- � ��,L�� c� Dote Applicant CITY ZIP � � NOTICE TO APPIICANT; If, ofler making�this Cerlificale of ARCHITECTOR TEL. DISTRICT GROUP iYPE FiRE PROCESSED BY O Ezemp�ion, you should betome subjett to�the Workers' � ENGWFER NO. �p� Z=N` � U Compenso�ion provislons of tha labor Code,you must for�h• ADDRE55 �� `y �� �4 W wtlh comply with such�proviiions or ihis permit sholl 6e � R.' / TEL q STATISTICAL C1A55�FICATION APi. CONDO. (n deemed revoked. � � � � � �ONTRACTOR y �v NO. - i � �� Z LICENSED CONTRACiORS DEClARATION ' �� �- ���. 4AS5 NO.a'-�DWELL.UNITS - � � I hereby affirm that I am licensed under provisions of Chopter9 ADDRE55 2l7�7 L NO.� ��(�' ��R�P (commencing with Section 7000)oT Division 3 of the Business and . . IIC. - - Prafessions Coda,and my"lircensa is in iull lorca ond eflect. CiTY W �-�� . e1A55 C`�� BK � VALIDATION �S I 1 Y2� � f / �EfT L:�o STORI�ES FAMILOIES � CONE Lkensa Number tia Class ' - a �� ,\.? VAlUAT10N ConhaCtD��/t"�l/- ����I Da18 ���2�7 DESGRIPTION OF WORK N� � S� �O ' ❑1 om exempt under Sec. 0 � - GA I f I _. ADD � , . ./ ALTER B.BP.C.(or thi3 reosOn . ,. � O C V�" REPAIR ❑ S -�� - USE OF DOte: f%ISTING BLDG. ,S� DEMOL ❑ APPLICANT TEL. � Signoture . .. . . . .. FINALj��j OWNER-BUILDER DECLARATION aRiNT tJ L NO. . OATE/—/� . � � 1 hereby aifirm�he�I em exempl(rom tha CoNractor's litense � �I '�^� law for the tollowing reason(Secfion 7031.5, Business and ADDRESS �z-� ! ��TL� � A1 Jl'' FINAL/y/' __—_� � � PfO�GlSiOfli COdeJ: ' � - PRE EN 6Y l� OBUIIDING I, as owner o(1ha property, or my employeef wilh qoDRE55 �woges as thair sole compensaiion,will do the work and � the structura is not in�ended or oNered for sale(Section ��`��TM 7044,Businets and Professions Code). � � MOVING - TEL. - � � I,as owner of the properly,am exclvsively conhocting COMRAROR rvo. �0 6 1,8 p wilh licensed comractars to consiruct the prp�ect(Sec- ADDRESS �f+ • • • • � tion 70AA,Business and Professions Code). [ONSTRUCfION LENDING AGENCY ��eq�K YARD Hvn TOiAPROPpIINE R WIDTVi � • •4 9�5 I hereby aiTirm that there is a conshuction lending ogenty for fRONi A (�,p aF= the perlormonce of�he work for which�his permit ie issved - P.L . D U 1 C"�Y�y y�+ (Set.3097,Civ.C.�. SIDE � v.i. Lendei s Name , e . IDMA Ref.M � lender's Address P.C.cea S � � Permit Fee � ' I tertify that 1 have reod this applicotion ond stata Ihat the Issuonce Fee �OhW P/C R ebove information is corrett.I agrea fo comply with all Covnly Inves++ga�ion Fee ordinances and Stote laws relating lo building canstructfon, _ . . . iorol Fee tDMA Perm.M eby auth ize represantatives of this Counly to enter upon th abova e f�d propert�ionJ p rpo es. � D ( J SEE REVE�SE FOR E%�IANATORY LANGUAGE ; � Siqnaw�e ot Appliconr o�Agenl � te � � � � � � � % � .� � — � � — � _c� c� T = t - - - - - - - - o 0 :� "c ° c° � 7 � � °� ` � o � � �? � m° � a � n �' � 3 � a'-_ ° ,p ° �. � - � � I � p :� �D � o ° o D „ o .'^r� �= c � r " ' , � z ; - . _. - �� v _ � ` d ,n �*+ R'c „ o f ' o p„ i 9 0 3� n� o � _ a o' v� '= � ° c �, ° R o n �'t' 3 0 - v o T o = < < � '. 7 ' .0 . p „ j n. � p . .f: » .G� 0. � . a ' j a �o; .� � _ " � ,.y :_o . ° � `o � _- � ' o : ° - , i rt • � � . � -- � . � � � _. . _ � _ ��� Z o v� �p 2 ' � • -- M �- • Io. n D c e �v J � � � • � n �� � Qa� z � � �. � � � �, , _ , , � . 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