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APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL 01 BL1kD11 ADDR
I hereby affirm that I have a certlRcate of consent to gaff insure, IAII f/G AD
or a certificate of Workers Compensation Insurance,or a certlfied 6 6 M` Le C1'7 gf�
copy thereof(Sec 3300,tab C) C"'•�,E,(yPLE ZIP 91-190 LOCAL"
Policy No COMP" SIZE OF LOT / (/ f NO OF BLDW NOW ON IAT
❑ Car#W Copy is hereby tumlehed 5n k /O a•(lt=__ NEAREST CROSS ST v ,
❑ Certified copy le filed with the county building Inspection TRACT
�� � ��
aepermhat 116E ZONE MAP NO
Date, Applicant A33E SM MAP BOOK PAGE PARCEL
53$3- y 39 ?J / �— / SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER N Y� IAO ' TEL-
Z O72�J YES No
COMPENSATION INSURANCE wrrmN lam FT OF SCHOOL?
(This section deed not be Completed if Vie permit Is for one hundred `y /C 1,100 DISTRICT GROUP I TYPE CONST FIRE ZONE MOCESSED BY
dollars($1130)or less) -
[� ,(e
I off*that in the performance of the work ler which this pent Cm L--L �orr A
lei,. I Mall not employ arhy person In any manner wa to rtECT N 7S NO
become"Oct to the MbdwW Cms
opaetkn Laws J STATISTICAL CLASSIFICATION
laAPT CONI%h
ta Appllwd ADDRESS Q' CLASS NO �Dw"ELL UNITS
NOTICE TO APPLICANT N, after making this Certificate o1 3 l06&E 5/- /v REQUIRED TOTAL 6EI6ACK FROM ExIST
Exemption you Mould become subject to the Ybrkere CONTRACTOR �"'� SETBACK YARD HWY PROP LINE WIDTH
provisions provons of the Labor Code, you must forthwith /YO/Ya� FRONT
co nilly with such provisions or this penNt shall be downed revolted ADDRESS LIC NO P L
SIDE d
LICENSED CONTRACTORS DECLARATION �' UC cA.AeS P L $
I hereby affirm that I em Ikermd under provisions of Chapter B SEWER MAP o
(commencing with Section 713013)of Dnviaiun 3 of the Business and SSUE YD NO OF oREe No of fAWLtEs NEW ❑ Bic PG I.
RofessIN Code,and my license m m fullforce arch effect � til
Lloonss Number Lx; ClassTl ADD ,�
a
vALUATN
ContData te / ALTER El $
m •'O poll. =
r/ry a
❑ I eexempt under Sec
REPAIR ❑
B BPC for this reason DEMOL ,❑ LDFAA Pros
DateUeEOF NG ' Kos / � URM ❑ --
nahue IPR r� TEL NOLOMA Perm1 = �'F�"_I I .r
1 sa owner 11 ie s property, or my ann"eea with wagse O ti�C r oc
their sole connperoebmh�will do the work and the structure le �/ hQ�f /C / F -�"�
not Intended or offered for sale (Section 70", Business and (e l . 14311AL OA7e a
professions Code) hruraAFRlrMrrnRRrWhE atxalwwrhuumuaAhnATAImOUerAAnssAL 1
❑ 1 as owner of the OR A Isnune CornvaerrG A RAZMooue hAATh3nAL Fnu,u To OR nRJAn THAN
property, ru ethe pr a contracting with raauouwroe moll ThE hwIMDOIq NATeauDiwaRMAroNlwcev Nt1Al
1k»nses and Profen to Goode) the probct (Section 71M4 YES❑ No
F,r
Business end Professions Code) ,7_I"~
wnL ra wrvom�err ra euamn er ra A{RICAIIi OR RncA¢euanRo
macMIrr AR QUALITY AFavwrroacaONsTrlCT(S ONAOORMMIoSEI!AMawnanCONSTRUCTION LENDING AGENCY wm ¢ MThee!3eounru
I hereby affirm that there Is a construction lending agency for van
Me pertcrmencs of the work for which this permit Is Issued(Sec
9 3087I Rcura =�
mA"GELE3 ----
-
5 Lenders Name C aiw as M renin�va ss hit THE ecAoli�m H&T!I
Landees Address
(.AfQfrl mfr
I umrtly that I ha1R read this apphoebm and state that the above PC FEE tEE
Information le correct I agree to con with all count' .
orWrhencce end S lens rNatl Ono end J
S Of la urposex
Lk
�l0 e�tef uppoon ISSUANCE FEE
Fxf the for p `:—
E INVESTIGATION FEE TOTAL FEE O
SEE REVERSE FOR EXPLANATORY LANGUAGE