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1141A 1271A 1272A (5)
WORKERS'COMPENSATION DECLARATION � ' f I hereby aiFirm thal I have a cerlificate of�o�=e�,fo Sa�F � �� �-.�APPLICATION�� FOR� �BUILDING -PERIV[l� ` � ���-- insure;or a certifimfe of Workers'Compensalion Insura�ce, . _ I ��,\ ' or o certified copy thereof(Sec.3800,Lab.C.� - CO(JN Y OF LOS ANGELES. .__ - -.. BUILDING AND SAFETY'��- �� PolityNo. � Company�HB - � � ' �O9`�S .�A� �^�U�� � Certif�ed copy is hereby fomished.. FOR APPUCANT TO FILI IN - nooaEss IA�rSS (� ��'/J�k� 10- Cenified copy is filed with Iha counry butlding inspec- BUILDING � �❑� tion daParimenf. ' �- ADDRE55 i� �10�c�{2�0.�`SIlAG'Eo(.lixTO � iocnuTv . c,z ., ' ' � � NEAREST Dote Applicont � CiT' 1L10N�,0 (3Art_. nP CRO5557. Q - O �� .-.CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BtDGS. �' ASSESSOR COMPENSATION INSURANCE �� SIZE OF LOT /U NOW ON LOT MHP BOOK PAGE PARCEI (Thia setlion need no1 be comp�ated if the permif is fo�one USE ZONe MAP 3'3 bundred dollors(b100)or less.) TRAR BLOCK LOT NO. {� '� NQ � ; . . ._. . .TEL...._ _ __.__. �X ,. -. SPECIAL / . } I certify thal in the performance of tha work for whith this ; OWNER �'�f ��.+ Yf �z+�rriirSNO. CONDITIONS�C lO O G 7� p, pefmit is issued,1 shall nol employ any penon in ony mannef - � � �-��� ��--� � �---- ---�-- - -� �.DISTRICT GROUP TYPE FIRE PROCESSED 6Y 0 ADDRE55 CONST. Z E �U so as to become svb�etf fo tha Workers'Compenwtion Laws. � _ �� .� � ... . � — Oafe ApplimM �.... ' UN�- -..--._. .-ZIP. ._� ...... ���� STATISTICAI CIASSIFICAlION. ., APT. CON�O. U ARCHIIECT OR TEL.a�/ NOTICE-TO APPUCANT: If, after making this Certi(itata of ENGiNEER � � G-' No.� �33'�0� ClA55N0. �� DWEILUNiTS � W �Exempifon, yau should become su6jecl to the Workeri X � .1 n f1,L�t �y Compensation provisions of the Labor Code,yov moit forth- ADDRE55-'y' �.� '-/l I J1�'� /p W -- - SEWER hu+P y � with tomply with such provisions or this permit shall be �1 � , deemed revoked. Cot�rtknCTOR P� �k NO.B/'7��� e. PG• � ' " VALIDATION -� UCENSED CONTRACTORS DECLARAT�ON � �i�, ��, { .. I hereby affirm rhat I am licensed�nde�provisions of Chopier 9� ADDRESS �S� JGU� NO. GAWH� VALUATION - � �� " , (mmmenting with Setlion 7000)of Divisio�3 of the Bosiness and � � ' ' %ofessions Coda,and m license is in full forte and effett. Ciiv �JL�''� G�(��'- QASS E '3C� � r.��� 4� � -� 27�4'3�. sca.�r. No.oF NO.OF CHECK License Number�� �t�.e�a5s�'�a. size STORIES ?� Fa,ruues oNe " r � � 1:• , •��•?_3 � . . . � . DESCRIPTION OF WORK In.vlp��U'U dY N� ❑ a ��J�� I • •G 7,17�j�... Contra[tor Dafe � ' ADD.__ --- "- ' . ❑I am ezemp�under Sec. � ���� ¢�7 � ALTER � FINAL - . ... ��� �C 7.�3`S' : . 8.8P.C.for thia reaxon . . . - . .- - . . .._-- .-- - - --DATE �oZi�'��� . . ' REPAIR ❑ I Z O J-i�S � Dafe: � USEOF .FINAL... ... . . . � . . - � - E%ISTING BLDG. d ��� � - � �EM��-❑ 8 - . . . APPLICANT G. TEL l.lh Y $Ign0lVfe - . .. _. ._._.. _.. _ . _ PRIM L� I�'1���� NO. -G�S6.. ' " .�� 2�I.� A OWNER•BUIIDER DECLARATION � � I hereby affirm ihat I am ezempt from ihe CoMractor's Ucense �{jo u, 4A 6�ta'�A� G.O�C.O. �jOoQ-[� ; � � Law for the following reoson(Sadion 7031.5,.Business ond ADDRE55 � ��-��-�-' // - � ,} • • •�•�',� . .. ProfexsionsCode): . � N ,.�- ' -�/�� - . . ❑ - BUIIDING �/�./ ��� • • • .�i J�� . . ' I,as owner af the property, or my employees with� �- ADDRESS �- ----- -� - - - �' -'� � { � .. .. wogesastheirsolecompensorion,willdotheworkand � �, � � ihe sfrocfvre Is not Intended or offered for sale(Section�� ����TY ---��-- �-� �� -�� -- � • � v�•;J� ? 7044,Business and ProfesSiom�ode). . MOVING TEL. � , ; ..� I,Os Owner of the property,am exdusively con}roding� . NTRACfOR � NO. � . _ A E- � .I 7 O CJ-�Jr �, .4V' with licensed comracrors to constroN the projed(Sea qDDRE55 - I - :�j 7 7,2� � -lfon 7044,Businass and Rofasstons Coda). . , ._ ._ _ _ . , .... � . _ . __ � � RE�UIRED TOTAL SETBACK FROM EXIST. � }�. • • . o � CONSTRUCTION LENDING AGENCY - � � SET sncK YARD Hwv PROP.LINE wi�iH� _ I hereby affirm that there is a mnstrotlion lending age�cy for FaONi� - �- -� ��� � � ��-�- -� � ��► -- � - --� � � -- � � � � � tba performonce of Ihe work for which this permit is issued � P.�. I • +4�i.�S i5ec.3097.Civ.C.). � SIDE . _ .__ - ___ . _ .___t ._.. .. . . . _ . . . .. .. _ . . -P.L .. ..__ . . . Lender's Name • ° •/1 C)7 r<' � . . . . � P.C.Fee 5 � .W�- PermitFee � . 7S_..i .. .. .. . . . .. . . . . � . � Z,U�`-?r Lender's Address �• � � p : _ ._. -- --_. ... .� . . . _.. 1 certify�that I have read this application and stote fhal the .7, �� Issuan<e Fee �•S� �, above informatton is corcett.I agree fo comply wifh all Coony imesr�garion Fee � � � � ordinances and Sfata laws relating to building mnslruction, . -. . . - . . - . ... ���- .' -__....__._ .. .. _... . _ . ' . . �6nd heraby authorize repre:entativas of rhis County fo eMe� To�ul Fee , -upon the ab ve-mentioned p operty for inspeciton pmposes. �� - � � �--- -- - - -�� ---- � - - -----��-- � - ���--- - � �� �Y , � „_ �Z.-Gj��, .:.,. . SEE REVFRSE FOR EXPLANATORY IANGUAGE_ _____:___,__ . , � Slgnature oF Applimnl Aqent. . . pote ' . . . .... .� . . . ... . .�s _ \ \ 2 � o . _ -�� \,� ! 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