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WORKERS'COMPENSATION DECLARATION - � �
� �nsurebor�ce�fkore ot Wo kea��Com'pensoton�nwron a" � /�PPLICATION--�-FUR BUIlQ1NG PER�l11T
oro cereif�ed copy ehereof�Sec.3800,tcb.C.i COUNTY OF LOS ANGELES BUtLDING AN�SAFETY
Polity No. . Comppny •
� Ceni4ied copy is hereby furnished. FOR APPLICANT TO fILL 1N ewto�r� 2� �
ADDRESS
� Certi4ied copy is filed with the cooMy boilding insper BUI�DING �` / ss
lion deporiment � AQORESS lY• L.•d .
oa�a nmeu�o�� cm A.�z�P / ioouin
- CERTIFICATE OF EXEMPTION FROM WORKERS'� �� - ���8��� NEAREST
�COMPENSATION INSURANCE 9ZE OF lOT rIOW Oni t0T Cft055 ST.
(Thia aecfion need.nui ba-comPfeted.if the pefmit ia fw-one . TRAC4 � �-- &OCK � �tQ7 NO. ....--� AMP BOOK =. . . � VAGE PARCEt
hundred dolims(SI00)or leu.l - �L.
OWNER ryp. USE ZONE �- Z.���7
I cartify that" � e performonce ot the wark fur which this /,��J �.
permi!is i ed.I il not employ ony�arzon in eny manner , A�� +� /�/6 " �� Cp�IT10NS ��
ao�as to 6 m 6ject to the Workers Compenwtbn laws. V
�� - - ._ �r�&^F� arv �3 nr (?f a
Pate ' �Appltcnnt ARCHITECf OR 7E�. M5ERICf GROUP NPE � FIRE SSED BY O
NOT APPLICAtdT:�If,aher maki�g�thia Cenificate of E��R t.ip. -- -.- - � 26NE� . . f—
Eaempfion,�yoo shnutd-beceme subject to the Workers �. .�- . .�� � - -- V
Gompanwtion Rvovisions o#.the lahpc Coda.You.mvst fceth' ppp�� � - � I � .-J �'� . . W
with.comply wlth suth provroiorts cr�th'rs permH--shCl{-be � TEL. STATISTICAI CtASSIFIC0.TION � � �T. . . . Z
deemed roroked. . . - .. _ .... � CIXJ7RACfOR . NO.
LICENSED CONTRACTORS DECIARATION .. tIC. 40.55 NO- �w�t�.UNITS ""
t hareby aff'rcm ihat t am licensed under�pror�aiona of�Chupter 9 ADDRE " NO. SEWER MAP ..._.. .. .
. (com�rcing With SecYon 7000)04 Dtviaon 3 ot rhe 8usiness and ---. .__. __. ._ . .. . tIG. _..- .:.. - . .. � - �- �
Profeufons Code,and my lieee�se i:xn fuf4 fwee oerd effeef. � .. dTY� . . _.-CtA55 - _. -&t. PG. -�. --- -.- . ._YAIiDATIFiFF --�
. . , . -. .� ... . -: 5�.fT. � NO.QF .. NO.OF CMECK
ticensa Numbir tic.t4o7i � �� STORIES PAMIl1ES � � .- -. --_-. . -- .
,:._: _ ._.. , - YJLLURFlON
� RIPt10NOFW(3RK��. A Nra dN" . �� � _-_—.� .. .
,� s �, � - z102.1R
Conrrodor oaro Ao o_E /NO �
�1 om sxempi undar Sat. _.. .:� . . � - ALTER �� .. . _ � � �• • �• � �
. JN oNc- ,�f ad f
8.8P.G for Thi1 ronwo � . ^ REvaR _ .. . ' � ��C.yr,� .
.._�Doteo . USEOF __. ._.._ .. ... . ��._ .__. ._.
- ��- � � E7(tSTING BIDG. -�- . . . -
_._..
.t$iqllOfU[B -... . : . .. _ F'PPLIGHT _.. TEL:. _ __._. . �'"�-�) 'i .:_ _. •a�♦w�:`J C c�_-• _.
- DAE Z7 �i U Q�,� G—�o
OWNER-6UItDER DECL4RATION PaiNT �� ✓ �
, I hareby affirm that I am exempt t[om the Contrpcto['s License qppaEu � �� . - _ . - NKu--_ .- -.
law for Ihe followinq rnawn(S�ctio�7031.5,Buainao and .. Q , ..
Wofesaiom Gode): -� - --:�._ , _. __...�__ ...__ ... Y
� euaoin� /
1,m ownor of the property, or my employees wilh ADDRE55 ��, � ,�/O�f�
-wapas aslhe�r sole compenwtion,wiil do rF�s workcw+d ��� � (��
� �he strecture is nof interded or offered for sole t5ecfion TEL � -
7044,Busineu and Profeasio�s Code)• . - � �V��-- . .. .
❑ MRACfOR �.
I;pt owner of the property,om exdusively confracting a�G�o
-wirh licensed coniractors to COnShuct�he p/D�e[I{$ec- ADDRESS
tion 7Qd�,Business arid Prnfessions Code�.
UIRED Tq7Al SEfBA K �
� CONSTRUCTIQN LENDkNG AGEMCY �SETencK �Y� --�� -�----PROP.ZINE-�"�'�- �wroiFi - ����n' � � / ^
I hereby offirm that there is o conslru<fion lending ogency for .pqpM7 �������_L ;/'�(r ,�.t�j„
Ihe perfama+cs of fie work for which this permit is iuued a.l. �/ - � - (� _
(Sec.3097.Civ.C.). SIDF
P.t.
l,endar's Name .� tpAAp,Rof.N
$ � .,. � .. R.C.Fa�S Permir he _ � ,
Lender's Addreu . .
� {�arrify IFwt I have read ibia appl{totiOn tlnd atote ihal 1hs hsuanca Fee /O� LDMA P/C N �
above infamWion i�tortect I ngree to comply with oU County Inve�tiqalbo Fea `
8 ordtnanc�s and-Stote laws rolating to buildin9 conitnteNo�, TWoI Fe�.. ����V IDMA�Pxm.M
R a�d henby aut � representnti�ea of this County to onter .
� upon the abo - .Ian�d WopKh fw inapsction pwposea.
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