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1702A 2428A
\VORKERS'CO:'.GENSATION DECIARATION � � � I hereby o{f�rm ihoi I hove a cenifico�e o�co�sen��o self APPLICATION FOR BUILDING PERMIT insurr.,or n cert�l�te�r.o!\"Jorkr.rs'Compr.nsnlion Insuroncc, o�a cer�ified copy iherecF(Sec.3?00,Lah.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Poii�yNo. Compony � � CertiFied copy�s hnreby furnished. FOR APPLICANi TO FILL IN euR�ir.'G -�`� � �' ADDPESS � Cerlified copy is(iled wirh Ihe counry build�ng inspec- BUiIDihG � s lion depo��mpnt. ADDQ:55 �/Za'� ST f'c/2 �are nppl�coo� arr //a.No�Jo �/!� zia / G.� : n iocnurv QrCv�C�`t� CERTIFICATE OF ExEM.PTION FRON1 V/ORKERS' SiZE OF lOi �JfG2 e! hOw O.v�tOTS. / NFJIREST �/ CROSS ST. COMPENSATION INSURANCE _ (Th�s sect�on nnr.d not be comple�ed if rhe pr.rmi�ie for one �J ��' � n55E550x hundm�l do�lor5(5100)o�Iess.) TRACT J QL 1� BIOCK l0T NO. �6S MAP?OOK 7AGi 7ARCFL OWNER��C�,�'/�� �G" NO. � ydT USE ZON, M1MP C I cerrify�hot in fhe per/crmance o1�he work for which t ' �� d � �.] permil is issurd,I shall not employ any pe o in anyfna e�, � SPECIAI � so as�o became subjecl fo Ihe Workers' ensa� l w. /DD�E55 �G��n'� CO\'DITIOVS 0 �/ [ITY li-�1 L- ZIP (/3 V �vDaie a APPlicant � ' � � ARCHITFCT OR TEL. �/� DiSiRICf GR�TYG: fiRE PROCE55'D BY O NOTICE T APP ICANT: If, of�er ma41n �his CErli icale f � /jC�4�V/L�/� hO.G3��7�9 ENGIhFER C(,•y5T 7n� U Exemp�ion, you should becoma subje �o �he Work. ' n n I rtf Compansofion provisions af Ihe Lpbor C de,yc�musl forlh• ADC7°55 %0•+i .0�iN�.:.�� �/• .%/i«.�!? l� � � \� W wiih con;ly wi!!� such provisions o� �his permil ehall be � n. deemed reroked. / TE�� ' SiqTiSiiCat CuSSii!CaT�fl� APT. CONDO. fn CONiRACi04 " L Lv/�p� NO. IICENSED CONTRACTORS DECIARATION ���. - CtASS ta0.�DYFlI.UNITS ? I hereby of!irm that I am licensed�nder provisions of Chop�er 9 nDD�E55 NO. yyyER MAP (commencing wi�h Sccr�on 7060)of Divis�on 3 01 rhe��stnese ond i��. � Profr.ssions Code,and my licens�is in iull forcr.ond e�fect. ' Ciiv CLASS eK � VAIIDATION SQ.FT, NO.Of NO.OF CMECK Licensn Number Lic.Closs SiZE� STORIES FAMIIIES CNE � �J� VALUATION CoMra[�O� Dale DESCRIPTICNOF WORK � X�y NEW ❑ S \Q�nf\ r� / / J / ADD ��11J , �� 7 Q�f+, �I am e.empl under Sr.e. !?� PU(� E ��e.J n�.��Q1cG� z ALlF2 � ii • • a e a � B.SP.C.�or fh�s reoeon � �'✓ v "'f� � REP�iR ❑ f Oate: ��E F DEMOL I • � O�.�� EXISTING eIOG. ❑ $ignofure A�F NTT iCS. %/�Z h0. '� D 9 FINAL � �� • • I lJ 1�.: i OWNER-BUIIDER DECLARATICN /' DATE _ j} I hereby affitm Ihat I am eKempl from ihe Conhac�or's licensn ACDRE55 L�IZ/�/�C��T` � C//L � ��1.G�—C%C% Law or ihe follcwing recson(Section 7031.5,Business and FINAL —Pr esstor,sfode)� vkt n 0Y EU!tD:NG I I, as owner o�tha preprriy, or my employees wiih ADDRE55 wage�as their sole cor�ponsotion,will do the work and �ha shuc�ure is not intended or offered For sale(Sr.etian �OCe.tiTV �O<d,Business and Profess�ons Code). MOViNG TEL. :�C�l G,C;!'. � � I,as ownr.r of the properfy,om extlu�ively conlroctirg CO`JTRACTCR Np. r . • . ' . 1 wirh licensed con�rocron to cansrruct rhe project(Sac- qooRE55 lfon 70<4,8uslness and Proiesslene Cede). . REOUiRED 'OiAL TBA R ii �� b ! ... CONSTRUCTI04 LENDING AGENCY 5�7 gq�K YARD HWv raCP.tinf wi�TH I here6y oifirm tha�there is a consrruUion Iending ogenty for FRCVT � ° � " !'%" the per(ormonce ol�he wark for which fhis permit ie I�sued v.i. _ _ (Sec.3097,Civ.C.). SioE • • � :.:� i;�_. P.L. lender's Name I �.� 4—i.�C�1 �7� r L�.VA Ref.N Lender 7 Add�ess P.C.fee f � Pe�mi1 Fee �Ci-1.1 1 cerfify Iha�I have read this opplicalion and slo�e Ihal the Issuon<e Fee /���� ID.MA P/G N � obove Iniormarion i7 correct.I ogree lo compty with ail Counfy Invesr�qviion Fee A ord�nances and �o�e laws r �ng�o bv�ld�nq construction, Te�el Fee ��t � toMn c�rm.N and here a rixe�pre n�otives o(�his Co�nty to enter; upon t v mentjf�Fed re erfy(or inepet�ion �rpo e(�s.l y� � Iv (J� SEE RFVERSE FOR FX�IANATORY LANGUAGE / �� �+�/ure ol Papl;canl or A,r!n� po� . y I, '/f��4 J O � ,; `�_�� �; �� T :; � . , , ��_ ��` - �.., � 'i G � �^ �_ � � �: i � o � `�: " ` ° " '�: .� ; � �= �. \ �;o . �'. � ; , o ,1 f � �- .�° ' `. u; �' °, ' ` y� �r c` U�' � • r ''' _ _ - ``,1 • ', � 'Y^ . y C `C%!'O` b yr n�� �^O . , \ �, `\ Z 0 .: ,�\ ^ = K •± \ '� \ � � 3 '" + \ J�_ o / �\� y ��. �,T ; t • Fi v,� < �. . : \� ,�1�-� F -o � � � - � G � .� 1 � `} . , � � � _ � , w i"'.� � ^ ^ < � �\ _ — < z �� Y � �. �' w G :- \`C O � 9 , �F . � ; // � r,`r •r� \ \� a y � �,� < � ' \� � � \ \ ` , �. , p , O. 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