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1582A
WORKEFS COMPFNSAT�ON DECLARATION I here6y affirm rhat I hcve a�ertificote of consent�o seH �PPLwCATi0�1! ��R �UILDING PERMiT � insure,or n ce�hhcote of Workers'Cnmpensation Insurance, � o�o cerrfied mpy therPof(Sec.3800,l.ab.C.) CQUNTY OF LOS ANGELE$ BUILDING ANQ SAFETY Poli<y No. �Company � Ce�r�f�ed�oPy is hereby f�.�ished. FOR APPLICANT TO FILL IN euuoiNc '� s �� �i,�„�j� ADDRE55 Z �J"'�( � Cerfified copy is filed wifh�he county bui�ding inspec� BUILDING � r� �1,���� n„�1. lion department. AD�RE55 a ��� �.•�� ��_ _ Do�e AQplicanl CITv '1 d� ��n+ ZIP L IOCAIITY .,y� -�[!' � � CERTIFICATE Of EXEMPTION FROM WORKERS' NO.OF BLDGS. NEARESi , COMPENSATION WSURANCE SiZE OF LOi NOw ON�OT CRO55 5i. ���y.- .,.,��- .� -L..�r- .,.:3 (This section need no�be compleled it the permit is for one �ESSOR ' hundred dollars(5100)or less.) TRACi BLOIX l07 NO. MAP BOOK PAGE PAR EL TEL p r USE ZONE MAF �, OWNER I certify that in the performance of the work for which ihis 0 � NO D v ""Z D NO. �,,, permif is issued,�sholl not employ any persan in ony manner -f /�/p (����� � .,..� SPEGAL � so as to become subjeci to the Worke Co p lion Laws. P.DDRf55 �/�-1 L D �(7+l�w� � ' CONDI710N5 � �� (��[ �aw �.�,r,t.q�w-� arv (It-µeu�9 �M�- na �l t1 p. Dafe ~—.K-s-=s-�Applicont ARCHITECTOR TEL. NOTICE TO APPIICANT: If, ofter making this Certificote of DIS7RICT GROUP TYPE FIRE PROCESSED BY 6� ENGINEER N0. CONSY. ���� ZONE � Exemp�ion, yoo shauld become subject to the Workers' $' i Compensation provisions of fhe Labor Code,you musf forth- qDDRE55 (,..� '� � .-�v^s.G N wi�h comply wilh such provisions or ihis permit sha11 be p�� ,C � TEL STA7IS71CAL ClASSIFICA7ION PT. CONDO. Z deemedrevoked. CONTRACTOR ���+ G �-�+V NO. Zi '� �� f -' IICENSED CONTRACTORS DECLARATION �6.�. _�•, n uC. �� ,� CLa55 NO.___c��_DWEu.UNIiS I hereby affirm that i am licensed onder pravisians of Chapter 9 ADDRE55 �� ���I`� q`� �G�� NO.� �� SEWER MAP �commencing wilh Section 7000)of Division 3 of ihe Business and O`AON h. ���� e-Y�� VALIDATION .Professions Gode,and my license is m fuli force and effett CITY I'�� CU155 BK � Q �f _ 50.FT-f NO.OF NO.OF CHECK LicenSeNumber • v Lic.Class� SIZE F�� STORIES FAMIUES ONE / [J��(/ �`�u0� VAWATION ' Contracror��� �6��� ��' D V DESCRIPTiON OF WORK NEW ❑ s ���� (�Q Date a / w � �t�� a 5/ ADD �I om exempt under Sec. �� ALTER � B.&P.C.for ihi5 reason REPAIR � S � -Date: USE OF DEMOL � EXISiING BLDG. Signature '4PP`pRINN) NO. FINAL /� � OWNER-BUILDER�ECLARATION �Ah ��t' I he�e6y offirrti that I am exempt from the Contrpctor's License Low for the following reason(Sedion 7031.5,Business and AODRESS FiNAi•� -^.j r�Q G i�' Professions Code�: PRE EN g1' � BUILDING �: i. +� a :• a I, as owner of Ihe property, or my employees wirh ADDRE55 waoes ns the�•scle cvmre.^.sa!ion,vr;!do i��e work ond A R fhe struciure is not intended or of£ered for sole�Section ���A��TY , � � �J`°`)(� 7044,Business and Professions Code�. MOVWG TEL . ,� ,� n(����'�?; � I,as owner of ihe ro ert dm exclusivel controcfin CONTRACTOR NO. P P Y, Y 9 C>�,�I .�)"'..Li� wilh licen5ed contractors to consiruc7 Ihe proiect(Sec- qDORESS tion 704d,8usiness and Piofessions Code�. CONSTRUCTION LENDING AGENCY SET�BACK YARD HWY T�TApROP.IINE R WIDTH I hereby offirm tha�there is a construcfion lending agency for FRON7 �he performance of Ihe work for which this permit is issued P.L. (Sec 3097,Civ.C.). SIDE P.l. Lender's Name �5-� ,�,..g"� tDMA Ref.R P.C.Fee$ Permit Fee .�d :o L�' ► Lender's Address I cert�fy that I have read this applimfion and sime fhat the issuance Fee ��• � LDMA P/C X above infarmotion is corred.I agree ro romply wilh all County Invesligation Fee ordinances ond Slate laws relaling fo 6uilding construction, Tolol Fee �� 3� LDMA Pa.m.N and here6y out rize representatives of this Coun�y to enter upon e abov - en�ioned properly for inspection purposes. �G/.tN .J�IrIJET/� �' f� SEE REVERSF FOR EXPIANATORY IANGUAGE $igno�ure al Appli<on�or Agent �ote . ........ _ , . . .. _ . . _ _ . __. , . .. . , . . ... _ . , , : , s � ; ' ' ; ' ' , ' , , ( "' ' ' ., ; . ; , --. � :�" .i ' ` t . I • � } . ` + . `3 � , ' I . I � , ' � , � ., •' { { � € , � ; �- � .. . ' ; _ i ' � 1 , , , j f � . i � ' , ' .� j � ' f � _ , , . ' � , .... ' j � - � . � . ..... ... '"'""� "'. :.............. ..... . ... ., . _. ' .. - � . . , ! ) I ' 1 � � , � Y . ' '__ � i • 1 . ' � ( n . ' , . . 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