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0841A 2795A 2797 (4)
IYlORKERS'CO.�"•^ENSATION DECLARATION ' � insurebor�afce!ri�fta1�r,of\Vorkesr�Com�pensa�on��;��P��" APPLICATION FOR BUILDING PERMIT � o�a cerr/ied coay+he�eof(Set.3?00.Lab.�/—) � � a COUNTY Of LOS ANGELES BUILpING AND SAPETY P❑olicyNo. �I3 Gompany "�`�'w'^�`T""� 6URCI4G 1' Cer+fied cepy h hr.reby furn�ihed. FOR APPUCANT TO FILL IN ACCP:$5 ��`� �Q � _ � Ceriffied copy ie filed wi�h the coon�y building inspec• ACCQ'.SS 7-+7 S�� GNaS� L��� ticn depertmeM. �o��e d� � Applitanl w� � G cizv �I�MOND A z�a iocr.utv . CERTIFICATE F EXEh1PTION FROM W ERS' SRE OF LOT 263� 5 p, NO.OF elDGS r NEF+4EST C041PENSATION INSURANGE NOW CN LOT 1 CRC55 ST. � (Th�s eeclion need nol be cample�ed if the perrnil is for one 2 -7 ASSESSOR ��, hundred dallars(SIoO�or lees.� TRACT 7O /S 9!OCK S 10iN0%F I MAP EOOK GAGE OpRCEI OWAER 7FfoMRS !��u NOv -¢ USE LONE MA� 'Q 7^��1 � I tertily�hae in�he perfermance of ihe werk fcr which this '/,' � .��I �,� N�' `��� � permit is iis�ed,1 shall nol�mploy any pe�sen in any monner pDDpE55 2.�r� Sr�� 1-L C 5Z '�-r-siY� ����A� � so as to betomn subject to thr.Vlorkers'Compeneo�ion Laws. A ri� CCti�ITIONS p C�fY �IAMOnIA C3 P Z�P " Da�e Applicnnl qRCHrtECT CR T«�C8[fI�_ I D4iRiCi G40UP ttFE fiRE �'�CESSED BY O NOTICE TO APPLiGANT; tf, o(ICr mo4ing thi�Cr.rtificote oS ENGiNfEe �-T`��N� C N0.1 �0.' ZOK' F-' Ezemption, you should become eublctt to ihe Workers' � �' U Compan3o��on p�avisions of 1ha labo�Ccde,you musl Iorlh- ADDQtSS �s.���. h��rnJ 5�. �e,H�}Makq lo �- � w lih com I wi�h such rovislons or ihie rrmi� shall 6e �' P Y P P� � _ /_�-�y TE' g'f��'�2�? SiAT:S:'ICAL ClAS$:FiCATION APT. COY7J. Z dCe�Rf�levOkp�. �CNT2ACfCR � �1 { LICENSED CONTRACTOR$DECLARATION i��.� RASS NO.�OwEu.UviTS I hereby al(irm�ha�I am licertsed ander provisiona af Chop�er 9 ADORES �A� "�>0�f� NO. 'r� �� �y��R IJJ P (cemmenting wiih Seclion 7000�o�Division 3 of ths 6usiness and uc. Prciessio�s Code,ond my licr.nsr.is�n full Iorce ond e��eU. C�Tv �rK O nn55 � BK � VALIDATION p /--/ (� SQ.Fi. NO.CF NO.CF CN'.CK License Num6er �/d �'1 C lic.Clns� r SIZE � S STC4iE5 FAM�liES ' CNE YAWATION ��..��/��L� � new CoMrac�orL1l�L._LC'�^�( Date �p`�-'g1 CEKR!PT!CYCFw•CPK DDf /OA( f'�� !'iST� F)1� ' ( FULL�I11 ADO � �I am exer�C1 under Set. ALiER � :%Q U 4.I fl B.BP.C.for�hts reoson g`pq'R S , , UcEOF ❑ .Z� DO[7 : . .ZJ �a": exisnv.e:oc. 51 N��(.� PHM�L °`•"OL ❑ Si9nOtUIR AP�fCR1Y7I . TEL. -! FINAL n I • � G�J Q` OWNLR-BUIlCE2CEClARATION � ����� ��� NO. 2' r�f'�7 DATE G�� �� � •• r 1 a j !:-.J V:J I he�eby offrm ihm 1 am e.empi 1rom tha Convoc�oi s License �a /,�, /�'�� Sr. r4�-N• �F}7/FC� low 1cr the foltawing raasan(Sr.nian 7031.5,Businefs o�d pDD:F55 FINAL ,� ProFessions Code): F2=•� BY �, � 7�� � aP.ULD!N3 1, p!owner of thc pra0erly,cr my empbyCes with ACD�E55 l/� wagr.s os their sole comFensat�on,will do the work ond ��' I"' ��• 1he slruuurn ie not in�r.�ded or affe�ed fe�sole{5?c�ion �«AUTY � ���n`- 7044,BuSinCSS Ond PfOfCSSlons COdCJ. h•OV:NG TE�• /'P � I,a�ow�e�ol�hr.prcperty,am ezclusively can�racting CONTRACIOR NO. z3 ^C�]�.J� wi�h licensed con!�oc!ors ro consr�uc�ihe preiect(Seo- r r�on 704a,Bueiness ond Prcfessions Code). %+��RE55 . . CONSTRUCTION LENDING AGEf�CY SF7 9ACK YARD HWY iVTA�RC�„LCtiE�� 'I �Y Dfli �Z�7 3 " � � � � I hereby of(irm rFat ihere is n conshuU�on lendin�agency for ru0'v� !U- `�.O��� � • I �5 Q J� �he peiiormvn[e oF Ihr.work ior which�his pc�mil ie iesued � P.�. (Sec.3097.Civ.C.). 5'=E � ^ � � �(1���u P.L. lender's Nome ^ lC!:A Ret.N � ��,L�"�l a P.C.Fee S ��� � \1 Pe�mii Fre O� � lender's Address ��7'j n- ^�' � I cer�ify thm I have�eod tfi�s opplicmion and stme thm ifie �Z•7 3 hsun�<e Poe t 0�v- i0!M v/C N � O.CM.�,� obove inlorma!ion i�correct.1 agree lo comply wiih all Counly i��ps„g�i,on Fee x�l 7� I $ ordinontes and Slalc laws relafing lo building tomtructian. To�ol Fee lv ���u tDMA Perm.M � �'�� and hereby ou�harize represen�ativcs of this Counly io en�er I� 1 opon�he ahove•ment�oned operty for inspr.ction purpases. ��� S'v ' � � l U—�^� SEE REVERfE FOR fXPIANATORY LANGIIAGE ��,� � S�r,no�u�e cl ApD ani or Agem Do�e Jo��—�7 _ — ----— _ �, r, _ Z -� — 1_ --!'C o 'r." � r c. �1 __ --;.� . --- - ---- � � _ � _ � t, -. =: - , _ s -�.^ , .: - � :. . .� �,. I a �: _ .. �� �; `— r i (: C 1 - ' _ � _ _ _ ... c: C� D � _ _ '; � . .. ; .. - _ -� "' �_ ' _ ; : I � _C �� 3 L1 �.C:��j S (1� 1 � p �II O II� _ -��7� , : ' � '' .'T- I o • c: , =. '' . •I N �'� . I, ` _ '' �= c �. 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