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. . . _.... _..._._._._... _. . _. ..._. .,"WORKERS'COMPENSATION DECLARATION • ' � .� . . � � � {'fie�eby affirm thof I hove a certificare of�o�,e�,�o=e�f - -- �APPLICATION FOR BUILDING PERM insu�e,or a cert�fica�e of Workers'Compenso�ion Ins�ronce, . or a ceriified co �he�eai(Sec.3800,lab.C. - " � ' � � C�(�r,?SPc� �,�;.��,.,.I�o�zq��f. COUNTY OF LOS ANGELES BUILDING AND SAFETY �cyKo. Company Certified copy is here6y furnished.. � FOR APPLICANT TO FIIL IN BUIIDING ADDRESS � Certifled mpy is filed wnh rhe counry bu�ld�r,q�nspee- � eu�ioiNc L (1 ,� tion deparlment. ADDRESS d ate���APplitanf �.7� ✓+J+- Cltt�CS' �—°" zm iocnurv - � ERTI I AiE OF EXEMPTIO ROM WORKERS' - � - NO.OF BLDGS. NFA¢EST � p � � COMPENSATION INSURANCE � SiZE OF tOT NOW ON LOT CRO55 ST. ��Q�Ltn..E-a%S' . ,�y�.o+J �a, , 'his section need not be completed if tha permit is for one n55E5SOR � � TRACT BIOCK LOT NO. /AqP gppl( PAGE PARCEI �ndred doltors(SI00)or less.) ,. , ' TE�' �J Z USE ZONE M�P OWNER �� NO.G '� YS�/ :artify thal in fhe performanee ef�he work for which�his �� ' rcmir le issued,I shall not employ any person in any manner L �], - SPECIAI _. . . � os to become mb�ect to the Workers'Compensotlon lowa. -- ADDRE55 �d �+ GONDITIONS � U fe' ApplicorH . � CiTY ZIP - - � ARCHITECT OR TEL. DISTRICT GROUP ttPE FIRE SSE�BY O 7TICE TO APPLICANT: I(, ofter making�thie Certifica�e of ti �mpHon, you should became aub�etl to the Workers' -- ,,n`n, ENGINEER NO. ��� Z�E U npensetlon provisions of the labor Code,you most forth- ADDRe55 � ' � ��� "� a�� W ti camply with mch provieions or thie permil shall be - /� c � CL' imed revoked: � , . .. � COMRAttO oV,.[ 1 NO 6�J LG-S STATISTICAL C1A551fICPTION APt. CON00. N LICENSED CONTRACTORS DECLARATION �� �� - - - 'M55 NO:� �"` D1A�(L UN�TS - Z LIC. . reby affirm rhat I am licensed�ndar provistons of Chvpter 9 ADDRE55 /3 ✓.�j�.Q��C,pyp. .3���.F imandng with Sectlon 7000)of Division 3 of the Businese and __., ��� �R�P . � essions Code,ond my license Is In fu0 force and eHect. cITY m/n.�4.w �cc� ae.55 C"3 - �eK. �. VALIDATION �seNum6er -30�To� u�.e�o:�'��C"�q ���� ��� s°e`��. SORI�ES ���� FAMi�s -/� -oNEK � � �� �� ❑ VAIUATION ' � . 'a[1a �-� �'6 , Dota 26 � "" OESCRI7IIONOFWORK-'- NFW S '1S'pp ADD � �� , am ampt under Sec. -� � ��b� �� - � , � AITER � .BP.C.for this reoson ._._. REVAIR ; � � � � �� Do1et ' USEOF DEMOL EXISTING eLDG. ❑ . . gnalure . . � ' AP�PRIMT Ot7 N N TNO. C(p 7�� FINAL � OWNER-BUILDER DECUIRATION .DATE . . . ' -. . _�- - -- -- - - -� Sy affirm iha�1 am exempt from iha Contractor's litense no0rtE55 7�f� � �2/�AI f.�/�� C-r flNAL� - � � " . >r the folloiving reason(Section 7031.5,Business ond ' sions Coda): . .. . .... . ..' cz N �Y . . . BUILDING `� � �,D n 1, as owner of�he property, or my amployees wiih ADDRESS � U�� wages as their sole compensotion;will do the work ond' � � 'he stroclure is not intended or af(ered for sole(Seclion ��'��T� � �� � � � � � �044,Business and Professions Code). -� � � � - -� MOVING �- - ----- -- --TEL.--- --� -- � - -- - - � - � ,as owner o(�he properly,om e.clusively cantracting CONTRACTOR NO. � • •4�O O vith litensed conMactors to construct tha projecf(Seo-� - -- -�-� � -�--- - -� � - � � �on 7044,Business and Proiessions Code). ADDRESS • •s 4-a n�� � CONSTRURtON LENDiNG AGENCY ' " sE�eac� � YAao HWY T�TApROP UNEF WIDiH � - •affirm thot ihere is a tanstrut�ion lending agency for �RpNT 0 8 2 6—8 8 �ormance of the work for which this permit is issued � � P.L. . 97,Civ.C.). SI�E P.L. Name SO IDMA Ref.N � Address - P.C.fro S� � Permi�Fee ' � - ' � hat 1 have read this applica�ion end srme thot the Issuonce Fee �d,S Q LDMA P/C N ormotion is mrrect.I agree to tomply wi�h all Couny Invesiigation Fee �s and State laws relaling to building tonstruttion, Total Fee- 0� lDM4 Perm.N �y oulhorize repreeenfatives of lhis Counfy lo eMer obova•mentioned properfy for inipettion purposes. � t���C✓Y�/h-t-. � Z� � SEE REVERSE FOR EXPIANATORY IANCWGE �lure af Appiicanl ar Agent re -' - - - . . ... . , - - . 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