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1'l07KER5'CO:'PENSATION DECLARATION 57
1S
I hereby affirm tha� 1 hovc a cerlificole of tonsen�to sclf APPLICATION FOR BUILDING PERMIT
insure,ar a ccrnf�cc�e cf Workers'Comp=nstlon Insuroncr.,or
a cen�fied copy itie�eof�S�c.3800,Leb.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N�. Comp�ny
Certified cc is hereb furnishr.d. P.u�LDtvG e�,/ G� H .
�'Y Y FOR APPLICANT TO FILL IN nor.vess ..� Y
� Cen�fied copy�s filed wi�h th=couniy buildinq inspec- BU'LDinIG Q
ticn depnr�men�. nc�FESS
�� ✓ ���C� .4 C IOCPtIiY _ ���K�
p;11r, �l liconl CIiV / �l �:FAREST q
PP /S Q/�:IP C/4 L� CRO55 ST. � 7 r)IC.
CERTIFICATE OF EXEh"FTION FRO."d WO4KER5' NO.OF ALDGS. ASSESSC2 �- �
CO.'A.PENSATIO'J INSURANCE Si2E OF LOT NC':/CY LOT � h•AP P.00K Pt.GF ppRCfL
�This seciion nend net be cemple�ed if Ihc permil is for one 7 U«(UVE rnna .
hundred dollors(5100)or less.) iRACi9�l RIOC!( lOT M1O. � �/ Np. a }
IF 5�[CInL d
�«,iir �ha�i��ha �,•:nrR _C_IY _�y'-J�q- ao.�° �oN��,�o�,5 0
y ����ormance o(Ihe wo�k(o�which this DiS1ItiC1 (;4(;Uv IVYt Fik. FY(XESSE RY V
rr.rmit is issued,I sholl ncl em�loy any prrson in any monncr pDDRESS �I � �E/.� �� CCNST.
so as�o bemmc subjeci�a ihe Wnrkers'Compensouon taws. . /�(� .,.
arr O_!f'�/2 n/G��� C'LZ(p l O J' V � �� G O
Dnla Arpli�onl ARCHIiFCT OQ � SIAl15IICAL CLl�S�S}IiICAiION �L / �Pf. CUNW. U
NOTICE TO AFPIICANT: If, r.(tcr mo4inq this Cerlificalc of FNG��:EF4 NO CLA55�JO. V_LD'�•�ELL.UNITS� !L
E.r.mpuon, you shoul� b^mme subjea to the VJorkers'
Compensaiion provieions cf�hr.Lcbo.Codc,you r.�us�fcnh• ,•,�ceess �
Sil':k�!�!AP
wilh comply wiih such �rovisians or �his p�rmi� sholl bo E` —
dr.emed rrvoked. C04TR4RCR ��� �;� ��(pQ ne.(� Mi�� VAIIDATION
LICENSED CONTR�CTORS DECLARATION
I hrrr.by offrm thct I am Ircr.nsed undnr provisions of Chop�cr 9 ACDCE55 lK.
�"n� � VALUATION
(tommencing w�•h Senie�7000)eF Division 3 of ih�Business r.nd ��`
Profess�ons Ced=,and my licr.nsr.is in full for���nd ef(ett. LITY C1n55 S d U� �
S(1.FT NO.CF Ivp.CF C�+ECK
Licensr Numbcr Lic.Closs SiZE STpR:ES � FA!A�lIFS � O�E
CESCRIPiICN OF WC7K h=tiy �1 S
Cenlrepor Dafs I n ^rD lEL ;
/
� I om exempf from Ihe licens�ng requirCmenls as I cm o — � (,tL L�
lice.nsed archii=u er a registered prefess�o�al angine�r nt7ER � FINAL �� (1�(1�'�
I octing in my prafcssional ccpot�ly (Secticn 7051, R�YA,R ❑ DATE
Busfness and Prolessicns Cede). USE C' FINAL �� � � �2 3
I F%ISiiNG 9LDG. CEh'CL ❑
Lic.or Reg.No. Da�e Acp�ICA'nT Tei. BY I •8 b$8 0
O:'.'�ER�9U�lCER CECtnRATICN i`4�tiT� '�'��.
I herr.by effirm thct I am e�amptlrcm itia Ccnrra�ror's I�CF�SP • •�j(j 8,8�
u
law{or i!:e fcllowing reoicn(Seclion 7071.5, business ond xC�J:F55
Prcfcssicns Codej: ' ��:.:�; O 2 G�!"$z
❑ � BUi�D'NG '
I, as owner of ihe proFr.rty, or my employr.es w�ih qC�;;cS E�P� e�p
wages as the�r sole tempenso�fon,will do�hn wo�k ond �x
�he structure is net in!ended or c(lered for soie(Se:ticn ���A��Tr �� �
7044,B�siness and Pro(essions Code). r.�pvvG IEL. i
� I,os owner o!ihe preper!y,ori r.rcl�sive.ly tcntra:iing cCnliaaCiCe h'o. a "
wi�h licensed mnlrncb�s to Ce�s��oU rhp pro�ecl(Sec- „�CF'S5
non 704a.Business and Prciess�ons Cod�J.
RFOU'REp Tpi�L 5F19A�Y FRU'•� F%ISf.
COYSTRUCTION tENDING AGENCY SEI gnCC ���� H"�� P�O� li!.E \'I!DIH
I herrby nf(irm th�t them is m m�struction Ir.ndinq agenty for p;;�y� �
�he�rrformonce ol rf+e work for which Ihis�?rmit is issued o� �
(Sec.3097.Civ.C.I. s'oF
P L.
Lendcr's Narnc /
'� lr.ndcr's Add�ess P.G�ce 5 (Q�O Pprmn Frn
W I cenify th��I hov.P rcad this cpplication cnd sloie iho�ihe kwonrn Fee
abovc infonna�ion is corrvct.I n��nc�o cemply with nll County
a Im�s��r,o��en Fee
ord�nonces ond S�ore laws rela��n��a build�ng construciion,
� nnd he�eby ao�hc��ze represeniaives af ihis Caunty io enicr TObI FCP
a �pon ihe obo�.e�meni�oned p�eperiy fc.insocclion purposr.s.
o SEE RFVERSE FOR E7(PLANATORY LANGUAGE �
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