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WORKERS'COh+.FENSATION DECLARATION �
I hr.reby e,�;,m ,�a, � ha��a�e„�f;«���f�o�,��,,o self APPLICATIQlV �OR BUILDI NG PERMIT
insure,or o cPrti(ica�?ef Nlarke�s'Compenslion Ins�ronce,or
a cr.r�ificd ccpy th��ec((5=c.3300,lob.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company p
� Cerrified copy is he�eby furnished. FOR APPLI�ANT TO ILL IN ACDDFSSG . .�(� ���0
❑ ! �.t.
Crni(i=d ccny is filAd wi�h Itie counfy buildinq inSpeC• g�i�plNG / C�' Q // �
�lion���ortment. Ap^7F55 � .�Lt�i iocauTv 1.�. , �/ �,��
NEAREST
Da!� Applitcnl CI7V Z�P CGOSSST. ��e�,�
CERTIFICATE C�EXEA".PTION FRO".1 WORKE45' ' NO.OF PLDGS ��) nSSES5C2 +
CO':�PENSATION INSURANCE SIZE OF LOT � ✓�:/L(. NOW CN l0T /� 1.1AP CppK P,aGE +�vARCEt
. (This secrion nead not br.completed if Ihe permil is tor one USE ZUVE �•��r
7RPCT P,ICCK l0T�O. �
hundred dollars(5100)or less.J �"/ n0 �� �j3
1 lEt. 4'[UM d
I ccrf�(y Ihof in thc prr(crmance of thc work iar whi[h Ihis OWNE4 �tN �� . - rao. �c'�r��� CONDITICNS O
rmil is issucd,I sholl nol em lo on / / �� Di5�21C1 GItUU� iYf'f flNf vVOCES'_ED P.Y V
F' p y y p^�son in cny m ncr pCC4ESS `J� . !�ttr( / �' y�t. /D CO!�ST� 70ti� �
so as 10 b..comc subjr.cl to Ihr.Workc s"Comrensatio (�aws. r �3 J � �l4� O
j' p `y' i "��' `�l�hs �rf
Dof�/ /� �S� A�pli��nl" �� l� � CITY Z�P 57l�!!SfICALCLA55''ICA710N AFi. CC'�'UO. ~
NOtICE TO APPLIGANT: if, o6or,k��p ih. r��Rmic oF AkCiniECT O4 G.,�yy TFI. �U
E*r.mption, you should becCme Subjecf �o'�r Workers' �NG!".'FR �� NO. CLA55 P:O.�.LD::FIL.UAITS_ p, .
H
ompe�solion provisions af�he leba Code,yca mosi fonh- nCCa[55 SEv:!R r.a> 7
w�ih comply wiih such provisions cr ihis permii sholl br �E� Y7 _/ t _
de�med re�eked. CC'VT2nCTC� � �-.. , NO.�/y 7�J�� Bc. CG;' VALIDATION
' LICENSED CONTRACTQ4S DECLARATION i1 7 r / L...•vLiC.�j C
I hereby olfhm ihat I om Ikr.�sr.d und^r provisions of Chop'er 9 aCDa�SS 0� °/ ��C�t�„� NO`,�1�''� VAWATION
(cemmencing wnh Sec�ion 7000)of Division 3 of the[iusiness ond LIC. )
Pro.^ssions Code,ond my I�c^n.e is in lull fo�ce onJ effeu. Ciiv C1n55 / � S /(1 �'TZ
� �c c,�� j�,�� w FT. I, e ,o.oF r no.o� l cF�:cK
license Num„�r lic,Class_(L.� 517E 17".� STCR'ES FA"'.qIES CNE
�� �,,}� ,Y`, CESCRIPiIC�C'l4CRK �"{'tC.i �+-c.�, NCW� � S
Cen�roc�cr -'+ti J � D�!c� AV� .
� I c�n o.emci from��'e I�cr.ns�ng requiremen!s os I am o �-�i j� f.� /�r.,.J ,
IiC(MSPd 02hi�?tt 0�O�!!�iSlp�P���p{CSSipI1pl p�9i0??� ntTE4 � � FINAL p '
atting in my prciessicnol ccpocily (Seclion 7051, . . ��a�i; � DATE �2�O O `� .
Business a^d Prcfess�ons Ccd�). �5�C� � FINAL
ExiSiinlG 9:CG 'l�'-vw/�f' CE/.•O: ❑ �� .
Lic.or Reg.No. Da!e AF�:ICANf /� /� �- ��0.�T�� y' By /
' O:'Jf�'ER.BU!LCER DECLARATIQN �FR"`T� �� !I �/6S�
I herebycffrm thal I om e.empl from�he Contro:tci's license ' G, ,L
law for t�=following����on�S�clicn 7031.5, 6usiness and �•^���ss ' � �0 9 3 9 P.
Prolessions Codr.): .,�i,; .
OEV!IC;tiG �d • • • • • �
I, os own^r eF ihe prcp=rty, er r�y er^pl�yces with nC�Fq55
wer,es cs their solr.compensa�ion,�a�ll do the work and O
!he s!�uc!ure is net iniend�d or cf(r.red!e�s��lr.(Secr�on iOCAlI7Y � . .�0 5
7044,Business and Pro(�ssions Code�. ��OV!1�G 1EL.
� I,os owner of�he properiy,om evclusiveiy con��aci�ng fCNi�nCTO� no • • •`]�,5 C ii
. wiih licrtnsed conrrnctcn b cens•ruct Ihe p.oj=c��S�o- ACCc-SS
iion 70dd,6usine5s and Pro�rtssio�s Ccde�. � I G Cl E�',-E�
CONSTRUCTION LENDING AGE�CY �'EL`UFEU �AQ' ��.��Y IOtni 5E7HaCK fuC�.� exisi.
$E1 9ACK f'RCP.L�NF W!'JIH ' .
I hereby afRrm iho�ihr.re n a co�s�ruc�ion iendmg nr,ency for Fk�y� ' � .
�he performancn of ihe work Ir,r w �ch�h�s pe.�mii n iswed p�
(Sec.3C97,Civ.C.�. SiCE � � '
�f!II(�f'f�5 N:Imf' �/
� � P.L.
�/{� P.C.Frrt 5 Prrm�i Frn /� �'� '
'° Lendcr's Address_ � � • � � �
� �/ /
W �certify Ihal I have rr�d i4is o,�plicotien and sta�e thpt rhe IsxunncP feo D• ✓O
Ia obovc information is correU.I nnree fo mmply wlth oll Couniy �n�e:��qo•�o�Fee
ordinoncrs and S�a�r. Inws rrintin�fo b�ilding tontiruci�on, A �`)
$ and hcreby authorize rcpresentativr.s of this Coumy to enrer Tciol F�e / ,�
a upen�ha above•men�loned .'cprrry(or inspnclfon p poses.
� �"ti� C "t,/�—� f� r SEE REVERSE iOR EXPIANATORY IANGUAGE '
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