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� WORKERS'COMPENSATION DECLARATION - ' �j
I hereby affirm Ihat I have a rertificate of conseM lo seif APPLtC�TIC�N FOR BUILDING PERMIT 's
insure,ar a cerfificate of Workers'Compenstion Insurance,or
a certif�ed copy thereof(Sec.3eoo,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. � Company
� Certified copy is hereby fumished. FOR APPL�CANT TO FILL IN BUILDING c�,// � � J
ADDRE55 •r �h'fw%'6 C��li'C
Cerlified copy is fi�ed wifh the-county uilding inspeo- BUILDING I�/ �1 /� )�
fi n d5� ADORE55 1�7 � NIUI G'�I�... LOG4LITY �ll�U ` � �
NEAREST
�ate Applicant CITV � ZIP � CRO55 ST.
C TIFICATE OF EXEMPTION fROM WORKERS' NO.OF&DGS. ASSESSOR
� COMPENSATION INSURANCE SRE Of LOT NOW ON lOT MAP BppK PAGE GARCEI -
(This saclion nead nm be completed if Ihe permit is fo�o�e TRACT � V BIOCK LO7 NO.�� u��� OP ��3 3 3
hundred dotlars(5�00)or less.)
,^� �^�� i`/' �
I certify ihat in ihe performance of the work for which this OWNER (� �tTN!�,.^� N �QO� CONDITIONS O
`permit is issuad,�sholl noi employ any person in any manner ADDRE55 �—J Oty, J"'UI.��Jl/�1� � -DISTRICT GROUP TYPE � FIRE PROCESSED BY V
so as to become subject to}he Workers'Compensation Laws. CONST. ZONE 'i �
�. /]{] /o /�a / c��i..�.��."-� p
Date Applicon� - GTY� UNU �/'7'/"S ZIP SiATISTiCALCLA551FlUTION - APT. CONDO. ~
ARCHITFCT O TEI. 7 U
�NOTICE TO APPLICANT: If, after making this Certificate of ENGINEEe w0�+ �� . . �
Exemption, you shaul�d 6emme su6jecl to ihe Workers' / L �CtR55 NO,�� . DWE0..UNRS_ p,
Compensation provisions of the Labor Code,you must forth� AC�RE55 s�',�� („�"1' $EWER NMP . � $
wilh comply wirh.such prvvisivns or Ihis permit shall be � r p� � —
daemed revoked. . . . � . . Cpp�TRq � hJ �tiE�TEo. U J �
V BK. pG, . VAUDATION
UCENSED CONTRACTORS DECIARATION r
I hereby affirm that 1 am licensed under pro+rrsions oi Chapter 9 qooRE� � �� � �. '"1 vawanoN , � �t b 9,4 A
(commencing with Sec�ian 7000)of�ivision 3 of the Busineu and 1-�n i��. ��,��U
Professions Code,or�d my litense is in full forre and eHec7. GTY� � !Y C1A55 .S b #����'Z 1
-/'1�'� SQ.F�. � NO.OF� NO.OF CHKK
_ License Num6yer Iq 1���] . Lit.Class �-- SIZE �U STORIES FAMIlIES ONE � .. .. . �.••4 9 8 4 �
�iV'C �� �� Z � . .:_... . .. . .. - : ' ' . ' NEW .� S . .
� � Y � DESCRIPTION OF WORK ' � 4�4 8�_ E
COf1�1OCtOf OtE ❑ ' •�• V r
� � 1 am exempl from fhe licensing requirements as 1 om o ��--- A 0� � +
i
licensed architect or a regisfered professional engineer . niree � FlNAL O�J.O�"a 2 1
; ac�ing in my protassionof capatity (Sedion 7051, .: .:� . .. � � ��. � DA7F� . T+...._ ..��j�i . ,_ ,
` Business ond Professions Codej. -� -� � .. �� usE op.�-. aEvain !���i ���,
k . . .. . . _. .__ . EXISTING �.. . � . DEMOL Q ..-gfNAl ..
Lic.ar Reg.No. Date APPU TE. Y' . . . . .
-�- -- -- ON'NER-Bl1KDER-OEC[RRAf10N-----� �-� f�iNi tdQ..� .
I hereby offirm that t am exempi from the Contractor's Liwnse ��i/ �'�j.0 Z�7�� .
Low for ihe following reason(Section 7031.5, Business and A�DRESS +c•r'"—
ProfessionsCode): . . � , pee5eN7 �rt�� „--y' j
❑. .. . . - BUIIDING . �dyl� Fic.v,� ' . . '
I, as owner of the property, o� my employees wiih ADORE55 �fif'"" �
• waqes as�heir sole compensotion,will do the work and . l� , j
. ihe structure is nor intended or offered for sale(Section ��A��TY -'� . - �
70Ad,Business and Professions Code). MOVING TEI. � �1 7 2 O A , �
� 1,as owner of�he property,am exciusively contraUing CONTRACfOR NO. .
wilh licensed mnlractors to consiruct ihe project(Seo- qpDRE55
tion 7044,Business ond Professions Code). �� � ' � �.�
RE�UIRED TOTAL SETBAIX FROM E%IST. - �
CONSTRUCTION IENDING AGENCY SET&4CK �ARD HWY VROP.LiNE WIDTH �•,� �9 Z 5 Q ��
I hereby affirm thm there is a consirucrion lending ogency for FeoN7
the performance of the work for'which this permit is issued v.�. � •� •9 7.5 0=
(Sec.3097.Civ.C.). SI�E �
�� '` o3G3-$2
lender's Name �/ `� �'
$ Lender's Address P-.C.iee S /-F . � Parmif Fee � .(�+� -
,?, I certify ihat I have reod ihis application and state ihat the Issuonce Fee •�� �
iabove informotion is m t I ogree to comply with oll County Inves�igarion Fee . ��q
$ ordinonces ond Stafe laws relating to 6uilding consiruction, To�ai fee ��•3l!
ond fiere6y ��ize repr entativ�es of Ihis Coonty to enter . ,
upon the a ve- ntione praperty for inspection urpos s. �
� � �"��� SEE RFVFRSE FOR ERPLANAiORY LANGUAGE , � •
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