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0890A (4)
_. . _. ... ..._.._..--_....... .......... ........_.. __...._ ...._ !s7 WORKERS'COMPENSATION DECLARAT�ON � (� � I heraby affirm that 1 have a cerrrf+cate of consen�ro self APPLICATION��FOR� BU�LDING P�E� � insure,or a certificoie of Workers'Compensation Insurance, or a crrified copy ihereof(Sec.3800,Lab.C.i -- � COUNTY Of LOS ANGElES BUILDING AND SAFETY Policy No. Company Q ce�,�f�ad�oPy�s hare6y fo.��ahed. FOR APPLICANT TO FILL IN aw�owc a 4 aq � AO�RE55 � Certified copy is filed wilh tha county building inspec- BUIIDING �� �� � �� �� ' . . � tion deportmenf. ADDRE55 �Q�.f��l/ Dola ApplicaM Ciiv ✓ �. zIP LOULIiV . CERTtFICATE OF EXEMPTION FROM WORKERS'� S�ZE OF LOT 6lG IO9 NO ON�LO 5 � - cR�oss�ST_ Q:1 COMPENSATION INSURANCE (This section naed nol be completed if the permi!ia for one � (� � - ��R hundrad dollnrs(SI00}or lecs.) TRACT 7'.r� BLOCK LOi NO.,i %u1,qP gpp( PAGE PARCEL ��' USE ZONE � I cer�ify�hat in tha performance of fhe work for which this �+NER �I` i �' !`i NO. pp permit is issued,1 eholl not employ ony parson in any mo r ��A� � So ae to 6ecome ubject to the Workori Co p p�,y . ADDRESS CONDITIONS Da�a �� Applicant . . W Ci7Y ziP � NOTICE APPLiCANT: If, aher makin � is Cehificofo of ARCNIlER OR TFL �ISTRICT GROUO TVPE fIRE PROQSSED BY � Exemption, you should bacome subjett to the Workers' EN � p �� �yp�SLL�,,q����� Z � U Compensation provisiona oS the Labar Code,you mv�t(orth• ADDRESS � � �.�'� l a W with comply '�h wch provisions or thfs pacmit shall be - a deemed revoked. . � CONTRACT '/Ld i.fr/Y' lCri6E�'�ir� � STATISTICAL CWSSIFIGTION APT. CONDO.� (n UCENSED CONTRACTORS OEGLARATION �� � iK.- CLA55 NO. DWEIL.UNI75 Z I hwo6y otfirm�hat t am licanxd urnlar pravisions of Chap�er 9 A�PRESS : �S L�✓� r+0. �P��� . . ., -.. .. . (tommencing witM Saction 7W0E of Diviaion 3 of tM B�sines�and � �R'� ���� � � � . �.+ Protessions Code,and my licanse ia in full force and eifed. CIiY L���✓�✓Q/�'/� QA55 VALIDAiION . y� . .... � . .�. . . . 5Q.Ff. NO.OF NO.OF CHECK .. BK... pG. . . LimnseNumbarf/� �0��-����c.Clau �'� SIZE �� �Q- STORIES� -- FAMIl1E5 �� - 6NE ��� y�UATION � CoMrocfo� Data DESCRIPiIONOF WORK L �� ❑ s 6�o--�.r�'s" � ��v�, �I am exempl under Sat. . . . � � .. AlTE2 �C .OQO B.SP.C.for this rcawn REPAiR � : � USE DF �pfe: EXISTING BLDG. �'C'� �� ❑ Signalure . . . . .. APPLPR1C,Nii NO. HNAI p� v J � . . ., �. OWNER-BUILDER DECLARATION . DAiE 6 "t`OB " � 1 here6y offirm t4wt V om s�ampt from 1M Conuactor's Llcense Law for the following reawn(Section 7031.5,Busineu and ADDRE55 FINAL �- Prafessions Code): �+e � � � - ❑ BUItDING ,. .. .. - 1, aa ownar of the proQerty, or my employeas wfth AD�RE55 '� �.�;-� � �� �' wages as iheir wle compensation,will do the vrorfc ond -� .. ' - ,. `��4�F+ tbe struduro is nof inte�ad or offered for wle(Settion �OC1`��tY . � .. . 7044,Busin�ss and Profosuonc Codol. MO�nniG iE�. ' +r• •• • • � � I,as owner of the praperty,am eadvsively COnfratfing CONTRACTOR NO. , . , . ...___ ' �,.'..- wifh lieansed coMratlors io tonstruct the project(Sec- qooaESS � . ' 1 1 ��� tion 704{,Bu�i�esa and Professions Code). . . -. . . . . . UIRE YARD MWY u . . ' • s i � `�,1��� LONSTRUCTION LENDING AGENCY ser eqac PRpP.LME WIDTii � 1 hereby affirm thot tbero is o consfruttion lending agenry for pppM . . � � . . �$.� 9��`j the perfarmonce of the work for which this permit is�awed v.L , . (Sec.3097,Civ.C.). SIDE P.L . .. _ ._''_' . . -._ . lerder's Nome {y ���f:.x_.- $ P.C.fee s Permif fee �0\ Q ..�. . �a�dara,ndd�a� � � I certify�hat 1 have read�his opplica�ion and�tate Ilwt the �uuonce Fee (�.SQ IDMA P/C M obove information is carM.I aproe to comply with all County �nwarqerion f�s r�� � $ ordinoncoc and Sta1e lawa relatinp to buildiny cOnslroction, , Toml Pes .`.�� LDMA Varm.M R and hereby aufhorize repr sentotives Is County ta enter . . � upon fhe obovs-men i r ion purposos. . ' , ' �- � . � ' ifE tEVFNi!!OR EWLANA7011Y LANGUAGi � � Si arun of limnf w Apenr pota N ' �S .� py � ~ i.'�'` r . �. ... . , c,.;3 �' K`" s %' '..:�a r.�: � U � n ._. -�`. {; ,�.w �� � d. ' •7 F -�.-.• ~ C L' ' '•� � C..:' � nL d. t � �j n -L �� d �' .' C : .. x � �► f $�� : .^~._. , . � .��'�� �� � �„'`. �� .� X � . ,' �. � , „y V�, y',y,. G ^�� . �..�.� ': 6i �`�.F G„� . C' r . � .. ^ y` � ;N'� J� " _ .n ^ , _,,,� O . .�`, `„ _ �' � _ ::� ... � C C ' � �w^3 � r � �'�f.. i .. .�. � G -. = " _ M1'r-. 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