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WORKERS'COMPENSATION DECLARATION - � �
� �nsurebor�cerrfkore ot Wo kea��Com'pensotonenwron a" � /�PPLICATION--�-FQR BUIIQ(NG PER�l1iT
or o cereif�ed copy ehereof�Sec.3800,tob.C.7 COUNTY OF LOS ANGELES BUILDING AN�SAFETY
Polity No. Comppny •
� Ceni4ied copy is hereby furnished. FOR APPLICANT TO fILL 1N ewto�r� 2� �
ADDRE55
� Certi4ied copy is filed with the cooMy boilding insper BUI�DING A� / ss
liondeportmenL � AQORE$$ �Y' L.•d .
oa�a nmei��a�� citv A.Q z�P / ioouin
- CERTIFICATE OF EXEMPTION FROM WOftKERS'� �� - ���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. .....--� MqP BOOK ` . . � VAGE PARCEt
hundred dolims(SI00)or leu.l - TEt.
OWNER �p. USE ZONE �- Z.���7
I cartify that" � e periormonce ot the wark fur which this /,��J �.
permi!is i ed.� II not employ ony�arzon in eny manner , A�� +� /�j/6 " '� CpPpIT10NS ��
ao�as to 6 m 6ject to the Workers Compenwtbn laws. �
�� _ ���cS�F� arv �3 nr (?f a
Pate ' �Appltcnnt ARCHITECf OR 7E�. Dl5ERICf GROUP TYPE � FIRE SSED BY O
NOT APPLICANT:�If,aher moki�g�thia Cenificate of E��R - .Mp. -- -.- - � 26NE� . . f—
Eaempfion,�yoo shnutd-beceme subject to the Workers �. .�: . .�� � - --�� V
Gompanwtion provisions o#the lahpc Coda.You.mvst E�th' ppp�� � - � J � .-J �r'� . .. . a
with.comply wlth suth provroiorts cr�th'rs permH--shCl{-be � TEL. STATISTICAI CtASSIFIC0.TION � � �T. . . . Z
deemed roroked. . _ .. _ .... � COPI7RACfOR . NO.
LICENSED CONTRACTORS DECIARATION .. uC. 40.55�O- Dw�t�.UNITS ""
t hxeby aff'rcm that 1 am licensed under�pror�aiona o4�Chupter 9 ADDRE " NO. ..._.. .. .
. (com�r�cing u/ith Secrwn 7000)04 Dtviaon 3 of rhe 8usiness and __ __, ___. ._ . . .. t�c. SEwER Mna . .. . - .- .
Profeufons Code,and my lieee�se is xn fuF4 fwee oerd effeef. � .. CITY . . _.-CtA55 - -� &t. PG. -�. --- -.- . ._YAtiDATIFiFF —�
. . , . -.. . .. .. .. - 5�.R. � NO QF .. NO.OF CMECK
ticensa Numbir tic.t4o7i � �� STORIES PAMIl1E5 � � .- -. --_-. . -- .
,:_' . - -.. ' - Y/1WRFION
.. � RIPt10NOFMK3RK��. A Nra dN" . �� � _-_—_ .. .
,� s �, � z102.1R
Contractor �aro qp o_E /NO �
�1 om sxempi undar Sat. . _.. ��- _. _ -- - � - ALTER �� .. _ � .. � . �... . . �
JN oNc- ,�f od . . .. .
B.SP.G for thie reowo � . ^ �Pw�R � i
- -- _ � • •�a�o
_�,.: ��� __ __ _ � _
- ��- � � f7(lSTING BIDG. �- . . �
_._..
.'.$iqllOfU[B -... . : _ .. _ F'PPLIGHT ._.. TEL• - ' _--.-' . �'"�-�) . .— _. •a�♦v�:`J C c ..
OWNER-6UItDERDECIARATION PatNi �' DAE Z7'�1 �: ..
Q�� G—�O
, I hareby affirm that I am exempt t[om the Contrpcta['s License qppaEu � �� - _ . - NKu--_ .- -.
law for Ihe followinq rnawn(S�ctioo 7031.5.Buainau and Q , ..
Wof�saiom Gode): .. . . :_.:�._ , _. __...�:__ ...__ _.. Y
� euaoin� /
1,m ownor of the property, ar my employees wilh AODrtE55 _ �, � ,�/O�f�
-wapas aslhe�r sole compenwtion,wiil do rFu workcw+d t�� � v (��
� �he stnrcture is nof interded or offered for sole t5ecfion TEL �
7044,Busineu and Profeasio�s Code)• . - � �V��-- . .. . -
❑ RACfOR �.
I;pt owner of the property,om exdusively confracting a�G�o
-wirh licensed mniractors to COnShuct�he p/D�e[I{$ec- ADDRESS
tion 7Qd�,Business nrid Prnfessions Code�.
UIRED Tq7Al SEfBA K �
� CONSTRUCTIQN LENDkNG AGENCY �SETencK �Y� --��- -�----PROP.ZINE-�"�'�- �wroiFi - ����n' � � / ^
I hereby offirm that there is o conslru<fion lending ogency for .pqpM7 �������_L ;/'�(r ,�.�j„
Ihe perfama+cs of fie work fw 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 .
� 1 cariify IFwt 1 have read tbia applitatiOn tlnd abte ihal ihs hsuanca Fee /0� LDMA P/C N �
above infamWion i�tortect.I ngree to comply with oll County I�veatiqalb�Fea ] `
8 ordtnanc�s and-Sate laws rolating to buildM9 constnteNon, Towl Fe�.. �.t���V IDMA�Pxm.M
R a�d henby out � representntirea of this County to onter .
� upon the abo - .Ian�d WopK�y fw inapsction pwpose�.
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