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WORKERS' COMPENSATION DECLARATION
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' insure by rafitm afcertif carte reof Wo ke sr1Compensat on eInsuran e, APPLICATION FOR BUILDING P E RM I T
or a certtiified copy theof (Sec. 3800,.Lob. C.)
_ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N000l Adacompony
'Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with the county building inspec- BUILDINGg
tion department. ADDRESS /6,/j� 1 L^ p�cf�
Date Applicant /;�NT�',� CITY 5015 lC /&T 21P LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO SIZE OF LOT SeSX / .s' NOW F BLDOS LOT ,� CROSS NEAREST
,
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one ASSESSOR
TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.)
TEL. USE NE MAP
I certify that'in the performance of the work for which this OWNER N - �. NO. v
permit is issued, I shall not employ any person in any manner '19i SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS g L'/� �� ��` CONDITIONS U
CITY G f�� ZIP /��✓
Date Applicant ARCHITECT OR TEL. DISTRICT,
NOTICE TO APPLICANT: If, after making this Certificate of ■*— .
Exemption, you should become subject to the Workers' ENGINEER CONSTZONE 0
h� GRP \ �{TYPE FIRE PR ESSED BY O
NO•
!3
Compensation provisions of the Labor Code, you must forth- ADDRESS v c V J a,
KI
with comply with such provisions or this permit shall be r�TEL. ,s / STATISTICAL CLASSIFIC TION APT. ONDO. N
deemed revoked. CONTRACTOR /d (3 /d�G ic.NO.c7� �(��
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS—� �. __ NO. SEWER P
(commencing with Section 7000)of Division 3 of the Business and LIC. 1
Professions Code, and my license is in full force and effect. CITY CLASS BK PG.7V�
VALIDATION
SQ. FT.c� NO.OF NO. OF CHECK
,License Number Lic.Class SIZE J STORIES FAMILIES /t ONE
NEW
VALU�A•fTI n.,�L]�Uv
/Contractor Date DESCRIPTION OF WORK ADD
D ❑ $ J r {" o
l ❑ I am exempt under Sec. �' dam/ (/\ v , .0}7 7
ALTER
Iry e,4f � � Q $ . o `
B.BP.C. for this reason REPAIR
USE OF 'a a 56
Date: EXISTING BLDG. DEMOL ❑
Signature
APPLICANT TEL.��A"�N � �/ FINAL . .s ✓L/GJ 7-87
OWNER-BUILDER DECLARATION'/ DATE
1 hereby affirm that I am exempt from the Contractor's LicenseADDRESS
� d� r�
Law for the following reason (Section 7031.5, Business and ` A
Professions Code): PR N
El 1,
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 2 7/ 8,Q 3A
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L. # 0 0 0 • oil
(Sec. 3097, Civ. C.). SIDE
Lender's Name P.L. - 29G,2
P.C. Fee$ Permit Fee f�� LDMA Ref. # o o 2 9 a 2 5.6
Lender's Address
I certify that I have read this application and state that the Issuance Fee � LDMA P/C# O 3.1 a 7
o above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee o LDMA Perm. #
and hereby authorize representatives of this County to enter
upon th I ve-mentioned prop rty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
nr Signature of Ap-pliconf,6r Agent Date