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HomeMy WebLinkAboutNo Permit Number (821) WORKERS'COMPENSATION DECLARATION �� I hcfeL�/affirm ihaf I hove a terti(icata oF consenf fo,e�f � � �qpp��CATION FOR BUILDING PERMIT ins�re,or o terti(ico�a of Workers'Campensotion Insurance, or a certi ied c�opy th �eo� Seoc.500���A)L 1Nn,G8 g]�d j.10 � 31 Z • COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. mpany . L ' ' Certified copy fs hereby furnished. BUILDING s) A , / ❑ FOR APPLICANT TO FILL IN ADDRESS .c, u ��+.�� � Certified copy is(iled with ihe county b�ilding inspec- BUILDING fion deporiment. . ADDRESS 2901 YuCatan PlaCe ��,iin. NEAREST , oare nppi�canr an Di.at'��Dnd Bar ziP 91765 ceosssr. CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. n55ES50R � COMPENSATION INSURANCE SIZE OF LOTOIIe Ipt SU}J. NOW ON LOT NOI1C MAP BOOK PAGE 7ARCEL (This section need not be completed if rha permit ts for one USE 20NE ^nna d Z—3� hundred dollers(E100)ar less.) . TRACT BLOCK lOT NO. NO. OWNERCdr�.SYJ2TCJ COT15t.CA. TEL. Q— C� SPECIAL } I'cenify tha�in iha performance of the work for which ihis NO. - CONDITIONS O. pelmlt is IssUed,I sholl not employ any person In ony monner DISiRI�T GROUP TYPE FIRE PROCESSED BY p so as to become subjecr to the Workers'Compensation Laws. aoortE55 28�0 28�1 $t. .j �_' CO�IW V CITY ]]1 d ZIP ''O "" � Date' AppIImM 9O4OS STATISTICAL C1A551FICATION APi. CONDO, � _NOTICE TO APPLICANT: If, ofrer mokin this Certificafe of ARCHiTECiOt�� T��•(213 451 tJ � 3mprion, you should become subjecf to the Workers' FNGINEER Vl't0 �ttd �17I1 NO. ? Q 3 C1A55 NO. �WELL UNITS�� w �mpensatlon provislons of tha Lobor Code,you mu:t forth- ADDRE55 1419 2r�d Street Santa hbnica SEWER MAP � wifh comply with euch provisions or this permit shall ba � deemed revoked. coNtRnttOe C3L'1Sb2L' COflSt.C#e. z� 0— 0K. pG, VALIDATION LICENSED CONTRACTORS DECLARATION � liC. I hereby oHirm thal l am licensed under provisions of Chapler9 ADDRE55 28�� 28�1 $t. NO. VAWATION - � ' (commencing wi�h Setlion 7000)of Divisto�3 of the Business and ��� .. Professions Code,and my license is in f�ll(orce ond effect. Ciiv Shcltd T'10711Cd (,'d. M55 t . � , 317237 B-1 SOE`�.5749• sToa°Fs ?% F MROIE$ 3 �oN� , �2 1 Q�A License Nomber Lia Class n DESCRIPTIO OF WORK L, N� � S��G DOV V �� � � �G`� �`_ � ' Contratror �C. $�7�RS 1 �I am exempt undar Sec. ` S ALER ❑ FINAL f °6 3 1•O O �' B.BP.C.for this reoson �[—, .� Q OATE — J • •6 3 1,0 0� I . . . REPAIR Date: USE OF 0 FiNA� . 0 fl 1 3-8 5 � FXISTING BIDG. DEMOL gY . ' � siqnature AP�pRir�T Cdrlsbex' ConSt.Co.No. 3 0 , . �� • � OWNER•BUILDER DECUIRATION � . , � , � I hereby affirm that I am exempt from Ihe Comroctor's Litanse . _ _ , .. . . . . . . law for the foliowing reoson(Seclion 7031.5,B�siness and ADDRESS Pro(esslons Codej: pREyENt � � I,as owner of the ro er y P Y _ BUILDING _ \ p p ty, or m em lo ees with ADDRESS J) wages as their sole compensotion,wlll do the work and i���n, - . .. �9 5 5 9 a tha structure Is no�iMended or ofiered for so�e(Section , , - 7044,Bostnass ond Professions CodeJ. MOVING TEL Q'� � � ' � _ � � �. �� e �'� � ,� � I,as awner of Iha property,am exdusively conlmtling �ONTRACTOR NO. � ; , wilh Ilcensed conlractors to construcl fhe pro�ect($e[- ADDRE55 _ � " - � �.�7�.�� tion 7044,Business ond Professions Code). ---- ��` , REQUIRED TOTAL SETBACK FROM E%IST. CONSTRUCTION LENDING AGENCY SET enCK YARD Hwv pROP.LINF WIDTH � • �,U�I��O O� 1 hereby affi�m that there is a mnstruction lending ogency for FRONi �� � - the perfarmance of the work fo�which ihis permit is issued P.L. i� �7 0 9�8 6 �s�c.soe�,e��.c.l• s�oe : ��'��.,'+ — P.L. . i m Lender's Name . 8 , . ��\�',��'� , = Lender's Address � P.c.F�e S ���,� Permir Fea �GO- '- _. . � . - � 1 te�fify tha!I have read this applico}ion and stafa that fha Issuonce Fea �0'S� I � abova informatlon Is correct.I a9ree lo comply with all Co�nry Inves�iqotion Fea r� � � g ordinonces and Stota laws relating fo building constructlon, Toral Fae �"��/ �' � and he�eby aulhorize representafives of this Counry�o enrer � upon the obova•nentioned erry for spectlon purposes. y��':_� �� � s—(i"sy � , -)3-�°jr— SEE REVERSE FOR F%PLANATORY LANGUAGE Signarme of Appiicant or nl Do�e . 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