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0851A (4)
•' WORKERS'COMPENSATION DECLARATION � � /G � � f`��I , I hereby affirm ihol l have a ceriifico�e o��o�=e�,�o,e�f � � - APPLICATION FOR �BUILDIN� u insure,or a certifica�e of Workers'Compensation Ins�rance, o.vj�rliiied copy Ihereof{Sec.3800,LobQ�.)n� COUNTY OF LOS ANGELES BUILOING AND SAFETY Polif�/�y / j Ly Np�� �'zapmpany ����' BUILDING � Cerriied copy is hereby t�rnished. � FOR APPLICANT TO FILL IN nooaess f� �'I �. � Certified copy is filed wilh tha munfy building inspeo � gURDING � A � p Yl tion departmeM 2 nDDRESS /� / G /,J Dote LV�(���APPlimnl,�[�C�� CITY ZIP {� C� LOCAIITY - CERTIFICATE OF EXEMPTION FROM WORKERS' - � . NO.Of BtDGS. . NEAREST �� COMPENSATION INSURANCE S�ZE OF lOT NOW ON l0T CROSS ST /� / G A�rJ : (This eatlion need not be completed if�he permit is for one . - � . ASSESSOR i! hundred doltars�5100)or less.) TRAQ BIOCK� lOT N0. MqP BOOK � 7AGE / PARCEL . TE�' USE ZONE �P p I certify�hot in the performance a(the work for which this OWNER e NO �,�p, y .�.4�3 ,..� permil is iesued,I shall not employ any person in any manner SVECinL �� so as to become subject to the Workeri Compensafion Laws. �� A�DRESS CONDITIONS U; Date ' Applicant � � QTY ZIP � NOTICE TO APPIICANT: If, ofter moking�this Certificate of ARCHITECTOR TEI. DISTRICT GROU7 ttPE FIRE PROCESSEDBY O Eaemption, you should become eub�ect m�the Wo�ker5' . ENGINEER NO. -- CONST. 20NE �""� Cempensation provisions of the la6or Code,you mosf forth- qo�RE55 �p W wilh comply wilh such provisions or this permit sholl ba _ . _ TEL STATISTICAI C1A55�FICATION APT. C NDp. � deemed revoked. . .. COMRACTOR NO. '� Z LICENSED CONTRACTOR$DECLARATION y/� LiC.. C1ASS NO. � �WEtI.UNiTS � �/ I hereby affirm that�am licensed under provisions of Chapler 9 AD�RE55 .C..�l NO. ��R�p (commencing with Section 7000)of Division 9 oi rhe Busineu ond �i�, y� � � Professions Code,and my license is in full forte ond effect. GITV � CIA55�'�7 BK. �. � VAl10AT10H 50.FT. NO.OF NO.OF CHECK Limnse Number 35��"IS lia Class G "3� � SIZE - STORIES FAM41E5 � ONE 7 VALUA7T7ION I� � � Date �J�� DESCRIPTION Of WORK N� ❑ S / / ��] CoMroctor ADD � (O v v ❑I am ezempt onder Set. �!x'�'� ALTER ❑ , �0 8 5.1 A 6.8P.C:for this reoson � �e• RE7AIR ❑ s � � #• • • � • � ... . Do1�� USE OF �`j�� G�J� 4S$JC DEMOL ❑ . EXi511NG BLDG. � � �'�(j,'�5 Ci��..n�.. � APPLtCANi � TEL. Q� /n FINAL �. // OWNER-BUIIDER DECU+RATION 7t�iNi NO. F �� . DATE � 2"0 � .. .7 4.2 5� I hareby affirm thal I am exempt from the Cororactor's Licenza " - "- lew(or 1he�ollowing�eason(Sectlon 7031.5,Business and ADDRF55 FINAL�� � D H,� 2—H H Professions Code): aa N BY � OBl11lD�NG t, as owner of the propeny, or my employees with nD�RE55 wages as thelr sole compensation,will do tha work and - � tha structure is not inrended or offered for sole(Setlion ��`��T� 7044,Business ond Professions Code). MOviNG ��� � I,ai owner of 1ha property,am exdusively eoMtatling ��NTRACTOR NO. wilh licensed confractors to tonslrucl Ihe'projecl(Sac- qpDRE55 l e�'Q_�(J� tion 70a4,Bvetness and Professions Code. o�-ig�� � � - CONSTRURION LENDING AGENCY � � SEanCK �ARD HWY �OiAPROP.L�NEFR WIOTH /(� /J � � I hereby affirm thaf thero is a mnslruction lending agency for FeONi /"�(` ��O 1 the performonta of the work for which this permit is issued v.l. � � . (Sec.3097,Civ.C.�. SIDE P.L. Lender's Nama �' LDAM Rel.X lender's Address - P.C.fea S Permit Pee � �- ,� � � � � - � I tertify thaf 1 have read Ihia application and slote that tha Iesuance Fee 1� "�a LDMA P/C N obove informoUon Is corcect.I ogrea to comply wi�h alI Counry � i�„eeugouon Fee ordtnances and Sfo1e laws�elafing fo building tonslruetion, Tohl Fee . •�. I�MA Perm.N and here nuthorize representalirm of this Counly to enter , , ,�� � upan e ve•men'oned ert for�n�u�se�^ ' - . . . � .. . . ' . � � O, O' . _ . . . SEE REVElSE FOR E7(PLANATORY IANGUAGE Signalore ot Applicont or Agent Dote _ ' . � , , o 0 . �� � ,C' `� O r �` - � �' ma o ' a v � n ' - v o �� ^ co o ^ b o � D • a O 7 � �� .fl i. '.G n � '. � , Q . � or O t� p � �U � � . �r o � o _. o a 3 0 ;, o .. 'm T V' O N �` ip C�'� Q G . � .. . 0 C p 7 �7 1� Q ,e .. 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