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WORKERS'COMPENSATION DECLARATION � �� �� � ��� �; .: � . ... �. � ��A .�... . , / 6 �� II
insure orafc'errntificarelofWorkeseCo�mpens�tlonlnurance5or APPL�CATION� F�R���UILDING PERMIT !S
a certifled copy thereof(Sec.3800,Lob.C.) COUNTY OF LOS ANGELES �� �� ` BUILDING AND SAFETY
PolicyNo. Company ��N��L��
� Cerritied copy is hereby fu��ished. FOR APPLICANT TO FILC IN �"' �' Ap�°Eu ��J S� �� S�� �(s'��
� Certified mpy is filed with�he co�nty bu�lding inspeo- eUILDIKG �7 ,/ ��/
tion depariment. ADDRE55 .0 �Lf �L'/dd� LOCALITY �y�S
Q y' Cy/ /_/ �p/ �l�/ NEAREST • /
Date ���'�+! Appli<anl ' � y M C�TY jJ HL 1+�14 IIP CR(1:S ST "' CO �N
CERTIFiCATE OF EXEMPTION FROM WORKERS' , NO.OF BLDGS. ASSESSOR
COMPENSATION INSIJRANCE S�ZE Of LO? NOW ON LOi � Mq7 BOOK PAGE PARCEI
(This section need not be wmpleted if ihe permit is for one 7 s^ U5E ZONE MF+P � �� �
hundred dollars($1001 cr less.) 'RACT.3�i�� BIOIX LOi NO ' NO.
� - s� !u„7 [- {' � � SPECIAL �
I<ertif that in Ihe erformance of 7he work for which this �`h'NER _ J i ��l/(�. . J ' `(� CONDI7iON5 ()
permit�s issued,I sholl nol employ any person in any manner qDDRE55 �fp�� `�' �u���,� �ISTRICT GROUP TYPE �� FIRE PROCESSED BY �
so os to become sub�ect to the Wcrkers'Compensation Laws. _ �p CONST. ZONE
,4Gse 7 P"'" N, ZIP � ~� � l �
Dote Applimnt CITY . _
S�A?ISTICAL CLASSIFICAiION� APT. CONDO. CJ
NOTICE TO APPLICANT: If, afler making this Certificate o4 ARChii7eCTOa TEL �J / w
E�GINEER NO. CLFSS NO.�_DWELL UNITS�� �� �� �
Exemption, you should become subject ro the Workers' aTi
Compensalion provisions of ihe Lobcr Code,you must forYh- qDDRE55 SEWER MAP � �
with comply with such provisions or ihis permil shall be �j /�
deemed revoked. CONTRACTOR , ` �C. ��NO. 4J� BK „�PG,` VAIIDATION ?
LICENSED CONTRACTORS DECLARATION �/' R/� ��y uC p �id lQj��� �"P°f��✓
I hereby affirm that I am licensed under provisions ot Chapter 9 " a'JDRE55 {��S/h.1 ��fC! ti0.2.7��7i� VALUATION ����.a �-� ^��
'commencing wlrh Section 7000!of Divislon 3 of the Businass ana 1') ,Q/�'^ Llf � f����
Professions Code,and my license is'in full force and effect. CITY �.1� �'.I.�^C CLA55 � �� �G'� ��
Qy/�`y 54 FT. NO.OF NO.OF CHECK J
License Number �<3T 9�� Lic.Class � � SIZE �� SiORlES � FAMRiES ONE �
� �r P� �P"r�,f� ��``W ❑ g ���T�`��>f , .
Controctor �'� �*�•w ate r 'Q"✓f DES�RI7TION OF WORK
� I am ezempt from ihe hcensing requiremenfs as I am a , , � � A�� �-- .,.'l
:"��'
licensed architect or p registered professionpl engineer� , ALTER� � PifvAl
� ❑cting in my professianal capacity (Secfion 7051, . RE>AIR � dATE �j� �,��r.:�%' ..
Business and Professions Code). use OF / .-�.`�"!'"'
DEMOL-.❑ F!NAt
E%ISTINGB!DG. !� � g�,
LIC.or Reg.No. Dafe APPLICANT TEi.
PR�NT, � _ -�u�No. o� 9� -
OWNER-BUILDER DECLARATION l� Gi P� V f /C�
I hereby affirm that I am exemp+from the Coniractor's Lkense p�' /a A, �Q: f J
Low for the following reason (Section 7031.5, Buslness ana ADDRESS G f r7 6�
Professions Code}: PRESEN7 . . � �.-I 3- ��
� I, os cwner of ihe property, or my employees wi!h AD�R SS ,
wages as their sole mmpensation,will do the work and ,�Q'• � �
the structure is not imended or offered for sale(Secrion �OCALITY � /�'�'�'�- . r� �.c,_,
' 7044,Business ond Professions Code). •M,OvwG 'EL � .� � �+a-� - '
� I,as owner oF fhe property,am exclusively con'racling CONTRA�TCR v0
wlih licenseri conirocfors to construct�he projeci(Sec- qDDRE55 �
ticn 7044,Business and Protessions Code)- - „ . . . . _
4EOL11RED yqR'J HNJY `L'?AL SETBACK FROM EKIST. . �"
CONSTRUCTION LENDING AGENCY � sei BaIX aeOP.�'�.n�E '+�IDiH �
I hereoy affirm Ihat ihere is o conshuciion lending ager.cy tor ppp��r '
ihe performanre of the wor4 for which�his permit is iss�ed �.L _.
(Sec.3097,Gv.C.j. 5'DE ..:'r:�..-�' ' .
F�.
Lender's Name n "
Lende!'s Aadress _, P.C.Fee S � Gs Perm��Fez � , .
_ y+
I certify tha'I hove reod this.opplication and s;o'e that�he Issuance Fee
� above Inforrnotion is mrrect.I agree to comply witn all CeuNy I�.esilgaeon Fec 1-y�+
orainances and Staie lows relming ie building mnstruction, Total Fee � �`�
m ond hereby authorire repre Matives of this Caunty to enter
Qupon t ove-menticne cpeny for ins ecYion purposes. �
a _____��9✓`"6s W� � ✓L'�/ SEE REVERSE FOR EXPLANATORY LANGUAGE , .
4 � s�.o,�.��`_. oa,e �_
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��-�^�- --- ...... .. ..... .--_._.- "•...`._ 63,INEh'-IIUTL�3E&DF.CL RA d0�
PLAA9S SO APPLEeAPdS s�'�'��d��dQ�t������ I her;�Sa e�fiirm ihci 1 am�exsmp4��rom ihe Con}racior's
�.y_ .. . .� .. . ..�.-.-,.,,.-.�.-....,...-.....,,�,�,.A.,o.�� __�" ----.-�.
�.��, ' �2��t��� � —J� : e.:s� La for tne foliowing recson. (Sec 7031.5
. � Aga;arm•re� �- f'..s�,.,.,�.,d'rr�f.c��zr.sa:.C�dc:lSnycity,opcour.¢��whicfi
t(P^�c.� scfe �o. L°es4e --� ;,�erid;�as�,.'>a;:n%£ro�nnsirsxt�c3ter,e�Pave,uemudrsh,
— � ��y^ � �'�— — C::�f'�x:.1:2}'Si:":[Cddi"fII��TSO3'#3 t151353LtSflPC��QISOYCC:btYL'S
S^=-+��^.-�s'a _r.._.._.�....�._�
k
� � � �H� . � ibs a;.�I=,rzrS for suc.h ne:mid to,F{1e�si�rn��/s3aEamenS
�- � , , -- , :.'>at ne is dzc+;:..cc�p:s.+suar.e to tbe,bruvdsdona of 2be Cme-
� "� f irxctor's'Lfc�.sn T d,�f�y,Gpier 9j(temmeraczng wieh Sec-
,�_.i_� L �,— -�--' dion�7?GOJ n%Divisinr 3 j tf�e�xszieess�axd Prcfessions
� � � � . � • � � _±e;or:.��.3iie;;exempsefierefrcq;dndtlsebasca�or:ne
� .- - ��;'c„ar?r:xsv,r,�`�:;'r:sn.Fr.y.;an:�rdose of$¢ct4ott�7�31.f by
�_...Za2rt:red .�_�'A i .P w, �."".�::�`,':::fLt,rt.l(]:.^.rCYH1:E51lIljEC:SSIIEQp�I.CRWClOAC4L'SL
iSi.].R@�9.LR.,. �
���C3'Jai3 6P 61[J9�5iJ0�? --•----- fiiE,"_'Ji.`'.�'��f3D:fJLGl�e(i6i:f:fJB jJ1dN/�YE(m L�'JI:QCS ISS�Qf.J�
p� � �� I ' - � I,a>cwr.er of sy�propsrfy,or my empleyeas wifh
_�—. --�y� `-
� LVater Certificate Y �I� I ��� m ( -- � '.v.d�es'ds their sole compsnsation,wiil de the vrark,and
�`�^ � t _ . . ____- �_ iho atructure is r.et infended or offerad for sale(Sec.1044)
HeaitF.Department I I � . � ,.. . �����e,:azwl'rof3ssaazs Code:The Consrxetor'sLScen;a
f !,s;r'�cas;aod a;;p1y io¢ot aa»:�ar qfProperdy xuho blsiids
Fir�Crpanme�� � ----- -�-�---" --- �:i+�;�ra�u�s;bereaa,and u�bo doer sucb u�orla�iimse f or
_� tl3vcxs�;� ;�is own �;nployees, pronidad thcs such a»:-
C,a���9 p:r,:>arxarets cre nnt :rttertdc-d or fjered fot sule. if,
,3�u�r.u�r,t'ar baaddx�rg or dr�¢roverxsrtt xs sold mithin one
Geolo�icc! . -'-- yeer?f ca�:e�ensa, i�a nwrec�bx:4odar u�d8 bdve c&e
b:�r.len r,;`fms,ir±F tbat 6e did not busPd pr ivnprove fo:
, __—__ — ;d;a�>xe,p:>sen(smdai.
Pe�Sestrien 1'roicctiun
(nenca)(Cenopy) � � ' � � � C' I,esownero4thcproperty,amexdusivelycontrao-
� - , �irro v�:!h lice�,���d�eniracicn to consi�uc;fF�e Froiect(Sec.
Speciai Inspettion �_ - 7CQ41 Raisansas emd Pro,essoovzs Cade: Tba CoxtracErw's
I(Cor.t.1 lAlosonry)(Nla!?ing) _ � � '� � :,t'-'^-F.�a;.�-���c'ass ssoia�;fh.y io a:a our�r.n,f�rop3r ywbo
� �,A _,� ���bu[!cls oi l%::�';s�'s'thcreox,and svl rs ccr.racts fas suc5
LoPDroir.aae ! I ' ' ��','icts e�%tr.`�a co�ztractc�:j licause�d du;xumnt to t.he
CnsnJrMcte,r'.s L,icearse Lrnwf.
- � _ . . _ . . ... .
�°'����� J^_^� _ ❑ 1 cm exempf under Sec._ ,6.EP.C.fortnis
--__I � � reason _
I�
� . � . . '. — — — _. fioie�_ Owner
_�a.,. �
&,p�:aaef� �e�4e !` i�ss�ee,or's Si3r.aAurc��
c-.=.-__.. �...�.i,..,_..-__.._ ...._ .n-..r-,-�ns..... if�5?'E�SO�'S WOTES
ILocatEon- \ ;
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Faundc4ions L'a_^!_�,'v- i -- ^".--. - �--
l Slcu - \ 9 _.(--
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I Fame !�� T1�i" �.<. � .
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Eneray In-u+�tion ��[/�7-C��� � _ _.
�� 7L.;1/ �i
Leth/Drywiall-- �� l . �.� ,..
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] !n52rior f
ia!h-Ex9erior !� • J � ' �• � �
�� L.� �'. _4'�r�'� � , ....
Flouse iVumber-- � . � � " -
�orrecf&?osted
Final- I
En1=r or F:oni �
, � �......... ��......J..�.�....,� __- ..�.� . .