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� WORKER$'COMPENSATION DECLARAT�ON � � . -: - - � �
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I hereby affirm thot I hove a ceriificate of�o�5e��,o se�f � APPII�CATION� ��FOR���.�BUI�LD�I NG� PE�RMIT��
insure,�_or a certifimte of Workers'Compensation insuronce, � ,..
or a certified ccr�y iheieof(Sec 3800,La6.C.)� ' � '" - � ��-- ��� �" � � ���� --- � � � . .
COUNTY OF LOS ANGELES BUtLDING AND SAFETY , .
PolicyNo .�� '- ���Company. - ---.. ----
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�� ;Certified copy is hereby furnished � FOR APPLICANT TO FILL IN AooREss �-d��� .�' '
' /C,ry!i}�4 C`
� Certified��copy�is filed wiih�the county building inspeo ` gUILDING //`, ��q - -
tion department. �� �- ADDRESSc,{�/ %t'/ � �J Y//�C
. .. . . ...:t- _ . .... �y ..
Date �. .. . ,.. Applicani'. . ..� `.� qTY .. . . ZIP � ���/ LOCALITY /� T �
CERTIFICATE OF EXEMPTION FROM WORKER5 NO.OP BL�GS. NEAREST -
� �� COMPENSATION INSURANCE . �� SIZE Of LOT NOW ON tOT CRO55 ST. �/2.� C �"�
(This seuion need>not be'�completed if the permif is for one -:-�-�` TRA�T 7,�q'l�f . � � - �! . � ASSESSOR ;__ _ - � ��� �:
hundred dollars(.$1.00)or.�ess.) . . -' � J ��K � LOT NO.��q �_ ry,p,p gapK'-� - - pAGE PARCEL �
�OWNER ,J��✓G �X+-'/�� � NO.���-33.C/ USE ZONE MAP �� >� �
I�certify that in the performance of the work for which th�s _ r, ��/�� NO. j� /�3 ,7 ��}
permii is iss�ed,I shalP not�employ any person�in any manner _ : qD�RESS `�✓/y����=� - ��ry�} SPEqAt - -���.
�so as fo become subject fo fhe Workers'Compensation Laws. - � CONDIT�ONS � .o .
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. . . ., :.,: ' ._-_. . _ ....,: �CITY - ZIP :� �.
Date Applicant � ��.
� ARCHITECT OR r�(/�� TEL � .,.DIS7RICT GROUP TYPE �� -FIRE PROCESSED BY � '
�NOTICE TO APPLICANT If, afte makin tbre-Certificate of � 7
4 _ ENGINEER �-U/«�' ,—/`.�^� NO.,c. �^ �� CONSL�._ ��ZONE
Exempiion, you should 6ecome s 6jetf ta,�the Workers' ' y y
Compensationi:provisions.7of ihe Labor;'Code you must forih- � .� �i. � ,J %����s �
: ADORESS L -/y7j)�,J/"YLU-�FiT�f f,.l�}fj 'O.
with comply with,;Such provisons or�this permit shall he � � L��-"'- -z ,tI)
�deemed revoked.� ,J TE�� �sj r�' STATISTICAI C1A551FICATION � APT. CONDO `.�;,'�
�: CONTRACTOR Q � � NO.�.ZS !aJ --: —
LlCENSED CONTRACTORS�DECLARATION -� � ii�. -_�C�aSS n�0._�1—owEu.`UNiiS � --
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I hereby affirm that I nm licensed_under prov�sons of Chapter 9 qDORE55 {rj�, �/�-jy�/� NO. � '
(commencing with Section 7000)o�D vision-3 of the Business and , _�� , ��� . SEWER MAP
Professions Code,and my license s in fu0 force and effecr ciiv-f� �O/„/C_ " ctass m - -gK, f� �� J - YALIDATION �
.. � , . � - �REFT�7B 5 OR�S 7 AMI�LIES / CO EK
License�Numher Lic.Class . .
�� - - VALUATION �
. .. . . .. ..... . � DESCRIPTION�OFWORK � /'� , /�'/�' DD ❑ S_ ��,,��G �
Contracror ��' -.. � Date / , ...
�I am exempf under Sec - �f��_ _- f���.���!^ ^�� ��
. �: / ALTER ❑ _ . ;�%C.E'F� �
B.SP.C.for this reason . :: ;. £' sfL- /� ��GS�C=T aePa�R � . S_.._ . . .:.. _.. .. . - � �: �
� USE OF i� ° a ° g '
. Date: : EXISTING BLDG. �EMOL ❑
. .. .Signature _ _ APPLICAN7 JL/ TEL. -...FINAI . . . _ � . 1 I C��.��;'l� _ .
OWNER-BUILDER DECLARATION PRinIT) � � !�/- il��`�l�O..S�'��'� . . DATE . �
���1 hereby�affirm thai I am exempt from the Controctor's license . ,-- - "' � O:%,U V�i .
_. ' _
- �ADDRESS �/�'%�<L. , ��:,
�Law for the follawing-reason.(Section 7031.5, Business nnd � - FINAL - :
-'Professions Code):�� . .'. ... .. . . . ,."". PRE EN7 ,.� By , . .". . ._ ' i 1 r^—u, ' `
�555��� BUItDING �___�Irr'� .
, I, as owner of the property, or my employees with ADDRE55 /, , � �
� wages as iheir sole compensatlon,will�do the work and r(�
' the siructure is not iniended or offered for sale(Sedion � ' �OCAUTY � ��J' .
` -�7044,Eusinessnnd�ProfessionsCode).�- MOVING TEL ,�(�) . - �
»� �
�_� I,qs owner of ihe property,pm exclusive�y coniracting � ��. CONTRACTOR NO. -._ ' �v : '
-with-licensed wntraciors to consiruct theprojecr(Sec- -���- � ����-�---���- - �� - / (� � . -
tion 7044,Bosiness and Professions Code). ADDRE55 .. / � ,,9 g� �
r�f�
RE�IIIRED T�TAL SETBACK FROM EXIST _ �'� f ��
" CONSTRUGTIONLENDINGAGENCY - - � � "�' SE7BACK YARD HWY PROP.LINE WIDTH /� �
I hereby affirm ihal there is a conslruclion lending agenty for . FRON7 � ` ��
ihe performance of the work for which this permit is issued � � P.L � . . ' �
(Sec 3097,Civ.C.). : SIDE �. . � " .
� � , . . .. � . .
\ ... .. , , P.L� :. ;
. . ..... . . .. . _....
Lender's Name �� - . �
� �� IDMA Ref.N �' i
- Lender's Address � P.C.Fee$ Permit Fee �J.� , . _� E
> 10, ,5a €
� 1 certify rhat I.have read this applimtion and state ihat rhe . ..,. i:suonce Fee �oMA aic fl � � � �
Q a6ove information is correct.I agree to comply with all Coun�y Investigarion Fee . -
ordinance,c'�nd Stafe laws relating to�uilding canstruction, _ . �Total fee -���-�-s ��.- - � �
w and hereb authorize represen�hve4o/ihis County to enter '°`iDMA Perm.-k � �� � - � � .
m upon abo>ve-mgP tro`ne/2A rope Ey fai mspection purpo s. p- � � � � j
� /' �._�y�{.! /'������'��C�r�..7 /l��'/(/J // SEE�REVERSE FOR EXPLANAiORV IANGUACE - � . �
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