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60 i ORKERS COMPENSATION DECLARATION
hereby offiftthat I have certificate of consent to self
insure oira certificate of Workers Compensation Insurance g p P l CkT I O N FOR
B U I L�Nd1
P E RM I T
ora
certifiAd copy thereof (Sec 3800 lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company BU
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRIESS
❑ Certified copy is filed with the county building inspec BUILDING cS�
Ti/on dep rtment / ^ ADDRESS
Dote �` ql Applicant L � CITY ZIPLOCALITY
NO OF BLDGS—
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT NEAREST
CROSS ST
COMPENSATION INSURANCE ASSESSOR (J
(This section need not be completed if the permit is for one TRACT BL4K LOT NO MAP BOOK PAGE101!:!V PARCEUen6
hundred dollars ($100)or less ) L 4/`!,W
OWNER TEN 41F) USE ZONE MAP
I certify that in the performance of the work for which this 'F5�/ �.e� p�
permit is issued I shall not employ any person in any manner ADDRESS f7 !�/"� u CONDITIONS - a
so as to become subject to the Workers Compensation Laws /y O
CITY V- t�N'N ZIP / U
Date Applicant ARCHITECT OR / TEL DISTRICT I GROUP TYPE FIRL_ti /PRCESSED BY 0
NOTICE TO APPLICANT If after making this Certificate of ENGINEER ` NO CONST ZONE' F-
Exempt°on you should become subject to the Workers y� w
Compensation provisions of the Labor Code you must forth ADDRESS /W-2/ lei �R✓ '� A6 � !/ 15K a
with comply with such provisions or this permit shall be L I L /�/ ,f� STATISTICAL CLASSIFICATION )�PT CONDO 4 la
deemed revoked CONTRACTOR/ h `7 1
LICENSED CONTRACTORS DECLARATION ADDRESS ` O�� NO cLE►ss NO v DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 LIC SEWER MAP SIT• —, .ate
(commencing with Section 7000 of Division 3 of the Business �j e SAL,. 423 m 3q,3
( g ) clrY ti` /!!O�✓TE CLASS v HECI
and Professions Code and my license is in full force an effect BK PG LIDATION
SQ NO OF NO OF CHECK
License Number `S 3� �/ Lic Class ' SIZ x STORIES FAMILIES ONE r s �" 'JJ
r, VALUATION �'} �yi� l.)iJ
Contractor �' �' Date '� / DESCRIPTION OF WORK / 1 NEW ❑ : 1 6C2 JL
ADD ElALJ
El am exempt under SecPoo. ,j� —
ALTER �>-lo�l'�'�RILNI`i t�.s/.27/5 1
B&P C for this reason REPAIR ❑ $ 94W 6f5
Date USE EXISTING BLDG DEMOL ❑ r
�g ..HEC�tG "2 l+_
Signature APPLICANT
� NO ✓/°,^(7f FINAL CHANGE j�°Z
OWNER BUILDER DECLARATION DATE
1 hereby affirm that I am exempt from the Contractor's License ADDRESS �6�°�Q jF �N 6W6CA- ar•
Law for the following reason (Section 7031 5 Business and FINAL
Professions Code) PRESENT By {�Qt_lff— L{ I,I 14/C s
❑ I as owner of the property or m employees with BUILDING i
P P Y YADDRESS IJ�IJE 1 AI's i°°,
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 - t
tion 7044 Business and Professions Code ) , 01.
CONSTRUCTION LENDING AGENCY S�BACK YARD HWY TOTAL SETBACKPINEFROM EXIST
I hereby off°rm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P L _
(Sec 3097 Civ C) SIDE
PL
Lender's Name gQ
P C Fee$ ✓ Permit Fee epa � a LDMA Ref #
Lender s Address �1
0 1 certify that I have read this application and state that the Issuance Fee �7 7— LDMA P/C#
0
above information is correct I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction Total Fee krzl/ LDMA Perm #
and hereby authorize repr tatives of this County to enter
upon the above menti ed roperty for inspectionr os
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si °tuf:;;0$066cant or Agent Dai