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1278A 1857A 1858A
� � WORKERS'COMPENSATION DECLARATION � � � � �� �- � � , �e�aby affirm ihat I have a certifitote of consent to seif APRLICATION FOR BUILDING PERMIT insure,or a ceriificole of Workers'Compensotion Insuron�e, orv�.ce�ted copy thereof(Sec. ? , COUNTY OF LOS ANGELES BWLDING AND SAFETY , Lab C. / �'"-..:. . .;Ctc�ti'?.. . �..�1,� t',. ,.:_�(. , ..,., .:� . .. P�olicyNo. E �:.- .Company ' .... . . ..��. � � . � .. Certified copy�a hereby fur isbed. �� FOR APPUC:ANT TO F4LL W aVito�NC';" ' �� Cerfified copy is filed with e c4un bU�Jding inspec- gU1tDWG . "' „ ,:. .- .'< .� A��ESS'' �ho1F d}epart ieni.� . l �j} fI { ADDRE53 .. � . � . ' � LOCAUN. . � --0ate I f.'. �APPlica t " ',.y'�...g{�� CITY�`: .. ZIP CROSSSSi. � . ... .. � . . � CERTIFICATE OF ExEMP O FROM WORKERS' � � �� � ' �"1. Y � � NO.OF BtpGS. ���. ��-� q55E5SpR � Y � . ��� COMPENSATIO I SURANCE SIZE C1F LOT � � ��-- ��NOW pN LOT � " . MAP BOOK � � PAGE PARCEL �" (This section need not be corr4pl�ed if the permit is for one �- � �� � � VSE 20NE nwa �.� g ��� V TRACT'', , .` BLOCK LOT IVO. :-.> NO. ;#e . . �. hundrod dollars($7�0)or lesa:� � � �� . . . . . . . .. . TEL �'� ,t,,:. : ' SPECIAL ,,,� .. I tertify that in ihe performance of fhe work for whith this OWNER` � - � Np, ' `" - CONOiTIONS � � �perrrrit is issued,1 sholl nof employ any person in ony manner � ��� �� � � DISTRIC7 .GROUP TYpE FIRE PROCESSED 8Y } � w as to 6ecome s�b-ecf lo Ibe Workers`Com A��` �� ` ' � �� � CON,ST. 20NE ., � � penwtbn laws. . ' . „. � ,. . f;_�' � . . . �.Date � � � A Ilcont... . � � c�n�:. < . .ziF ., :. .. ..� :... ,. � PP . . . . STA715TfCAt CL45SIFICATfON APT CONDO. O � NOTICE.TO APPLICAN7: If,.after muking-fh'rs�Certificate of ENGjNEER� - ' NO. � � � �Exemption, you should.be�ome subiect ro the Wofkers' � � � C44SS NO. DWELL UNIiS_ 'Compenwtion provisions of ihe Labor Code,you musi forth- - �� � - �� � W witbrcomply with�such provisioro or This permit shal! be A��� � ' � � SEWERMAP � - � t,,. � deQmed revoked._.• . . . � CO�viRaciOa� .�. � "�.�.. . .:tF1 : � : ' .�' �� LICENSED CANTRACTORS DECLARAAON�� . -.. . M1�. . ` ..�. eK. PG, YALlDAT10H = 1 hereb�affirm thof f am licensed under ravisions of Cha ter 9 ADDRE55 - � ` ��' � � '�-. ..a�,-; ^.. . Y P P ��`. t�. ' �`- VALUATlOtI �`�:�� . . . -(mmmennng with Section 700�}of Owision 3 of tha Busineas oad� - �� ` ��� [IC. � � � �: � Profess�ons Code,nnd my litense 5 in full,fprGe and eHetf.- . ��ty � �� � ��� . ' � � � � .. . •- '' SGI.Ff:- �NO.C?F NO.OF . CHECK : '�.i..I.:;�� � .Li[enseyumber � ��.�``.'i Lic Clou `-�x, SIZE �� SiQRIES � fAMIlIES ONE � - t .. � - �� �. .�. ..:.,,.. � �',�_ ,`:..�: �� � DESCRIPTION OF WORK .' .•:�- :. �� NEW � S h �',��.a,��.� ��1 } � - Controctar �-^'��' ` a^%` � Date � � r,. _. � , .. � _. . ADD � .� � ��:,L-�:s. t ❑1 am.exempt u der Sec. :` . ..�- , � - °.:� � � . . . . .. rr . . . � , �: . . .. ,.. � �:.. � ALTEB � �PINAL . . . ... !�,�.�.(,.L,i-i..; �� 8.8P.C.for thi repsOn " - � RATE � � . . � _ �� . . � . REPAIR � �!�_ U5€OF� � .0 ( � � . . . . __ `� ate: EXISTING BtOG. . . . pEMp� � B NAL . ... •-� . Signature ".•�. .��. . . APPl1CANf - iEL . Y � ER-BUILDER DECLARATION . � PRIN7 � - ...NO. . � l C„-./�`,. � I bereby offirro f am e:empt from 1he�Conimdor's License� � -- - � -� - � .. Law fw the f lo�log reason(Secfion 7031.5,Business and� ADDRE55 = . ::'. �- - � . ..� � � ' � „ t�r a�;',. . Profeuions e: � - . . . i(i,�� ;;,'�,i}r`: oe���o,�..-�---�� 1, as Q er af the property, or my employees with qppg�,5 , ... - _ �.wc�ges ns their sals compensntion,will e{alhe rsorkond. .. � �. . .. . .. . . � � . . . . . , � �,��= 3 �ocaun ,• • �: :kG�c,. � � .the snucture is not intended w offered for wle{Section _ ._ - � � � -� � � 7044.9usiness and Professions Code). � � � Idpv1N� - � �� � � � 7EL.� � r^r .�; '.- .�� - � � � i,as.owner of fhe property,am aac{usively contracfing NTRAROR � NO. � � ' .t:�';i:.�s with��licensed�ontractors to construct fhe project..(Sec- �� . �. : �. ; . � . � �tion 7044,Business and Profassions Gode).� �� � � �. .. . ��. . . � � REQI}IRE� ... . TOiAL SEIBACK FROM EXIST. . .. . 1 ; '�;(;+[y CONSTRUQION IENDING AGENCY �gq�K YARD Hwv pRpp,uN � wIDTM , ' � , . 1 haraby a4fu.m fhat there is a conshuction IenSling agency for � pqpNT . � . :y r�a�t���, the perfwmante of the work for�which this permit�is issued p,❑.� '�. tSec.3047�Civ.C.)� . � . � � . � . � 5��- . . . .:+���k G:�.:.'�` . m . . . . P.t� �: . . . . . . . .. . .. � .�< Lender's Name�� � � .. � �.� , . � . . � � . � .'.� 1 .. � . � �s4t�.�::�r,.� � Lender's Address .� . P.0 Fea �...� f � Pe�m�r Fea � ' ,..�� . . . / P r�"(�r .'�.� � � . . . }r.l�M T.'L:r.e: I cartify that I hrove read t s ppplicotion and state that ihe �'1. � �,' '�t' T . �ss�onca Fee � � � . .'< akwve�.inform ion is�Cm 1g9 rea to mmply with�oll Caunly � ���os�i��p�Fee � � � � � ordiriances a d Sta1�Ap rafating-W buiiding tonSFrudiOn. � � � � af� , ���;�.- . . . G and hereby. ihori ee resento ives of thia County to enter To�o�Fee � _ �� � < upon ihe ab� �e-me o prop rfy for�inspection purpofes `-• r � --.. -` . .- '. � � f ; r. ir , ,. • . a - �.~� -v-t� �` � ( ;.�,.� SFE REYERSF FOY'fXPUNA701fY LANGUAGE' � . � . ..S�yr�f re of Applicanrbr Agem- . pata, . . - � . �t t - .. . .. . . . . . .. . . � . . -- - . ._. . . , --- -.. . _-- - - , � I ; ; � - i ; ! � . ; � ,. � , ' :i , , j , � ' i' — �. I ' �� , � . ! � i , ___.._ , � ---- , , i . ' A . ' � . - ; . � � -� l ' � ' - � ; ' � . � 1 ` ' ; , i � , t .. � • ' ' � I, � % . I �--� - ----, --�- -� � I ! ! ' � i � f . ' � .. ' � .. �' i 'i 1 � . i � ' �'' j ! I ( ' I ,� 1 ' • � . ,-, � . . ; ; � I . . � I I i ! I � q ' . i: � � � �J ' k ' ' I � � , t ' ; .: ' � � ' i �v .. { i i �'; . i � , i I t I � � I , i ! � � � .. , � . ��' :�i � � � ! ; I i ' ,I I ; j.� I ; I � -, ' � ; ,.; . _ WS I � ! .. . I, � � i i j t . ..' �� � � ' � ' � � i � ! � ! I. �? �"i i j �.� i i � � I j � i �: � i t' ; j , � ; ! � . '� . ,:� I � ' R I � , - i I 1 1 �, � I.. I S —j-- -- i � �� i � � i� i � i i 1 I' � � � I i I "; I �. .. .., P � � _M.I � _ '� � i � � , � I � i j � I. . i ; i ^. . � � I � ; � � I � � i �, � i �, � ;' r. - . � � , �� - i .. � i � J � ; � i � I i i I� i I I i . ' i I . : i � ; � I �i i � j � i i 1 — � , , �� � � -''. : � I ! ' I � � � �� � f i i i � I I `. .' ' . . .� i. + i ^ i � i� ! ,1 . ` I I i '_ ."; ; i � � � � i � � « , . t ( � i�; �--I-- I. � � ��_ ' �� � � � � � , 1 � � i - . 1 K. I � � -� ,'.� � � �, �`� � . , j ' . j �., j.. � I I � i- � i .� ; � , ,'f . . ' �__ . _ : - .._ � ; , i � (� ' i � � I �; I. ' � � 7 . 3 .; ; - i ��I I ;',. �': . . . , 1' j I_ � I = i , . . � . _ i�� . ' . ' . .. . ...... . .. , . , . _ ' � . . . . . : � � .. .. . . . ; - . . . . .. , . . i _ � 1. -. - _ j , i . , �. , ' _ r �� .. � i = _ �, ; I I i i .. � _ -. ; � .. c � ' .. � - � ' i _ _ } i 1 ; . � _. ! " , � � � ' ,r� - _ ' , i �- . .� �: .� , .. . � � . : , - - , . . - ' ", . i _ ' - - . ..-_ - c.. , � ' - .._ . . ��_ _ � c. � - . � � i 1 . ! 1 , - ` � . _ i ,- - � ; ' - j . ... : ` - -- �� - � i � � - '. . �. � i ` . , . . _ -. _ .. . : '. -_ - - � - ' _ � I -",� . � "' .: . � � . . . � - ' _. ' _ _ c . , I . _ . � _ '- I � ' ., . - . - , ' . . . . ... ;; i ' . - _ , ' .. .rt � ... i i � � � - . _ ' i� . � ; 1 � � I ' _ . . - . � r t. . �_ , � ., . , i ' , . ' . : ' . . ' . ' ' - , . . � . , ; _ : � - . . : � , ._ . . _ , - - . � � . . : � _ �_ � _ .. . __ _._i � � � - .� � .. � . -. _ � . .._ . .__ �.__' � _