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WORKERS:COhLIK74SATION DECLARATION
1 hereby affirm that I have certificate of cement to self APPLICATION FOR BUILDING PERMIT Il'
insure a a certificate of WorWorkers'Compensation Insurance,
or/a/cKe�'tifi7 thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pcy No Company (�/em eA21-a
Certifi copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING
O
oi ADDRESS Zr �
Certified copy is filed with the county building mspec- BUILDING liv �'�
IIJJ non deportment yam' �,,r��I ADDRESS % LOCALITY 6
Tic, O �r ��j'// a NEAREST
Date Applicant r ffV, CITY ZIP CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS I OF SIZE OF LOT NUOT MAP BOOK vAGE PARCEL
DGS ASSESSOR
COMPENSATION INSURANCEON
(This section need not be completed if the permit is for oneZ Z USE ZONE NO OZ LU
hundred dollars ($100)or leu ) TRACT & LOT NO
SPECIAL ).
I certify that in the performance of the work'for which this CONDITIONS d
119
permit is iswed,l shall not employ any person in any manner DISTRICT GROUP TYPE FIRE SSED BY O
so as to become subject to the-WoLken'Compeput�n Lawa � � �, L �N3T 3 V
Date ApplimnI �zJ. xn CITY G ZIP STATISTICAL CLASSIFICATION OF810 0
NOTICE TO APPLICANT If, after making this Certiflcote of AR 1"ER C �„Z V
Exemption, you should become subject to the Workers' CLASS NO DWEU UNITS_ EERIER d
'Compensation provisions of the Labor Code you must forth- ADDRESS �� SEWER MAP 011111 Z
with comply with such provisions or this permit shall be _
deemed revoked CONTRAR SK /--PG �G) VALIDATION
LICENSED CONTRACTORS DECLARATION '
I hereby offvm that I am licensed under provisions of Chapter 9 ADDRESS _ VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC '
Professions Code and my license is in full face and effect Cltt CLASS 46 $ U ,
50 NO OF NO aF CHECK
License Number O �Llc 1149— 91 SIZE STORIES FAMIDE 14 ONE
Contractnr�C7� LI-0. Date�LJT If/G DESCRIPTION OF WORK 2;1NEW
��[[ ADO
f{�Ji am exempt under Sac
tADD ALTER ❑ FINAL` REPAIR ❑ DATEB8P C for thn remonF Date NG BLDG F Es DEMOS ❑ BYALSignature 1 TLt7OWNER-BUILDER DECLARATIONRINT 1 hereby affirm that I am exempt from the Contractors LicenseLow far the following reason (Section 7031 5, Business and
Pro ions Code) II, as owner of the property, or my employees withIN �� 7 / 8 3 6 2 5wages as their sole compensation,will do the work andFTYthe structure is not intended or offered for sale(Section7044 Businen and Professions Code) � NO . 2 • • b 8 b L1, as owner of the property am exclusively contractingwith licensed contractors to construct the project (Sec-non 7044, Business and Professions Code) ADDRESSCONSTRUCTION LENDING AGENCY UIRED YARD HWY TOTAL SETBACK FROM MSTI hereby affum that there is a construction lending agency forNT« PROP uN WIDTH 12. b— 2
the performance of the work for which this pemnit n issued(Sac 3097, Ci aLenders Na '/ T6 _ —Lenders Addree$ Permit FeeI certify that I have read this oppliccno and state that thauonce Fee lo, Sabove infomiahon is corrM �gtee to comply with all Countygetion Fee 1
®a ordinancm aid`State 1. :09 to building construction, Towl Fee /
and hereby authorize Jefemotives of this County to enter
upo ab m nad property for inspection pu s
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LTEE O1/ERSE Lwa EXPLANATORY LANGUAGE
Sipnvtu of Kpplicant or Agent � ma