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1769A 3491A
WORKERS'COMPENSATION DECIARATION �� � � ' � ' - APPLICATION FOR�BUILDING PERMIT I hereby affirm thot I hove a certi(icata of consenl to sel(I " . � inwre,or a certificate of Worken'Compensation Insuranca, �•� - � or a�e�tif��Gc re c��3800,tab.C.� 0. J� COUNTY OF LOS ANGELES. .' - BUILDING AND SAFETY � Po❑licy No. Company � - � ..... � .. , . B(11LDMG.,, Certified copy is hereby fumished. FOR APPLICANT TO FILL 1N no�aess ��Cerfified copy is filed wilh the tovnly building inspec-� BUttDMG �l �) tion department. . AD�RE55- O'�� S-� � -/� -� -�O� LOCALITY � . � ` � ' NEAREST Date.�-3�Applimnl t �� c�T`/ Ail 21P � CROSSSi. � CERTIFICATE OF EXEMPTION FROM WORKERS' . NO.OF emGS. n55E550R � � �COMPENSATION INSURANCE $tZE OF LOT NOVJ ON LOT MAP BOOK : PAGE PARCEL �(This set8on need not be cample�ed if the permit is for one � - �� ��Z �P — � hundred dollars(E100J or less.) TRAtt BIOCK l0T NO. � NO. . � . .� -/ � TEI. . _. C�� SPECIAL �/j_/_ YYl � OWNER /{/= O�CT� R J/�4N0. �/-.2OY�-fJ . CON�ITIONS 4C+ (�� /'� � I certify that in the performance of the work(or which thie� ...._. oisreia GROUP n� FIRE SSe08v O permit is issoed,1 shall not employ any person in any manner �� '- -�- . .� ' � �-� " "-��� - - - - � �ONST. ,/ -ZONE /�` ' V so as to become s�bjett to the Workers'Compensation laws. ADDRE55 � V .� ` . � — � . � CITY � ZIP STATISTICAL CL4551FICATION APT. CONDO.. O . Date � Applicant � ' . . . ARCHITFR o TEL. f� �j - .. .U NOTICE TO APPLICANT: If, affer making lhis Certificafe of ENGWEER F•V.� ��Ar{� S� � "-NO:-. - S � CLnSS NO. �+�—DWEIL.UNITS ' - a Exemptlon, you should 6ecome subject to tha Workers' /� Compensaiion provisions af the tabor Code,yoU mVSt fO�ih- AODRE55� %;Q o�arD�; ��ev✓ SewER Mna � - � with comply with suth provisions or�this permit shall be �}— ' Z deemed revoked. �OMenCTO '71'f f'�J-,ZE�J BKE'iG PG,�� VALIDATION IICENSED CONTRACTORS�ECIARATION - UC. 7 � I hereby affirm thof I om Ikenzed under provizions of Chopter 9 AD�aE55 Gn! . NO. /0��{� VALUATION � (tommencing with$ection 7000)of Division 3 of tha Business ond ��/ ���. R Profeisions Code,and my license is in full forca and effect CIN W QASS !l � s/S��� , ' - Licensa Number���I l,l/ . � SI�ZEFT TORI�ES FAMILOIES CONE . �� Lia Class Q s CoMrocto � Date�-3 � DESCRIPTIONOFWORK C! iCt= TIff�CM N� � _ . . _.__ - .. ..... ._ ._ . ADD. �.. . . .. . �I am axempl under Sec. - ALTER ❑ FINAL �� 7�9� �. 8.&P.C.forthisreason '� �- -' � ' � � � -� � - - - -� -- ' aEpAiR DATE�=l —�� � + • ' � ❑ ... �. • . .?j - Date: , USE OF ... . _. . . . DEMOL ❑ � FINAL- - � ._ . ' _. .. . EICISiING OLDG: - By � • •9 1,3 R � __ Signature � �. APPIICAM TEL . . . . .. PRIM NO. .. - - : .� .. OWNER•BUILDER DECLARATION � • • .'��.J B� ' I here6y af(irm that I am exempt from Ihe Contrador's Ucense law for the following reasan(Setlion 7031.5,Business and ADDRESS � "-��"�� �- '� �� ���"� �� 8 j ProfeSilOnSCode): . � . � " PRE N .�.. , . . . . `� - �. ❑ . BUIIDING � . . . . .. . . .. _ . . - I,os owner of the properiy,-or my emplayees�with � --- a�oRe55--------—---- �---� - � � - ��- � �� '�!!9.1 A. wages as their sole compensation,will do the work and � ' ihe siructure is not infended or offered for sole(Sectlon . �«A��TY � � � --------� �-�- "- � � , �" �� wah liee sedfconhac ors b comt�udsfhelp ojecf($e c A MIR SCTOR � ' NO. � ..._ . _ .. ._._ �... _. ... . -l 4���.�q�u�. twn 7044,Bosiness and Professions Coda). . .__ . .� .. -- � . � � �- � - � � REOUIRED TOTAL SETBACK FROM EXIST. � . , �, ,., . CONSTRUCTION LENDING AGENCY � SeT BnCK YARD HWY PROP.lWE WiDTH ► .'���' � � _ ���-�- � -. �. .. ..,., I hereby offirm�hat fhere is a conslr�ttion lendfng agency for : ppONT - ��� � �-�-�---- -- - - � --� � ' � � - -� the performance of ihe work for which this permil is issued �v.t. . . � � � . �Sec.3097.Civ.C.)• � ... SiDE _ _ _. -.. . _ .__ . . . .: . . . . . � ._ _. . . . _ . . P.L � .. , . ,..�. lender's Name � � � � .. . ._ . ._ . . . _ . . . . . . . . . .'. _ ._ _.. . - _ . _ . , lender's Address P.G Fee E Permit Fee � � � � . . _..__.._._.._ . _ _.__. ... . . _._: . ... .. . 1 certify that I have read lhis opplimtlon and state that the � - ' � Issuance iee � Q� � . . � - . abova information is conect.1 agree ro comply with oll County Imestigation Fee � _ � . � ordinances and S�ate laws relming to boilding construction, - � ��- �� -- � � Torol Fee � � ond reby authoriza representatives of this Couny to enter � - � � � u e abavo- n ione oper for inspecNon purposes. � - �� - . � � � �� � � �, - -� - � � - �` - - � - -- - �-� � " -�� -�' " J �,3 p,� � SEE REYERSE FOR E%PUNATORY LANGUAGE _ .._ __ _ _ . ... _ ' . . -- .--- - - -� � . . . .. ._. - Slgnature of Appllmnt or genf Date � � � � � � � ���� � . . __. . _.._ . . �.. . . -. _. _.. ._._ . .. _.__.. . .. . ., . . . . . . . . . . �i . y � _ o ° .- - --- - _"; - i _�- '_ � _Z' o '� Y 1 � .� c� �'�ti "W� a �, 1 4� � r n� �o. o a- O � r_ =��t � � _ �� p � �� ^� °�o m� �v �,r� �^ �.� � ��! p � � - � , ,� v � p � . � ° v: a._ i,t,�, ' o' � ' .� N .O ro�n .�, �a O_ -�� nj O,, �, � P•. ,Q_ . 5�.. �� `` ' r,l• m' * �. r' � 7 � Q'_ 7� O Q' 9.' _ , � O O b � q �1 �� (39� � r M� , ! 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