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1178A 1179A (5)
WORKERS'CDMPENSATION DECIARATION � , v hereby'offirm ihal�have a�g,�;f;�a,a o,�o�,��,�o.��f APPLICATION FQR BUILDING PERMIT �nsure,or a.certi4icate of Workars'Compensotion Insurance, or a certified copy�hereof(Sec.3800,La6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � Policy No. Compony Carlified copy ie hereby f�miehed. BuitDiniG FOR APPLICANT TO F�LL IN ADDRE55 2�07✓7 P.r17x/F/�vLL�i��eQ � Certifiad copy ia filed with iha counry 6uilding inspet• BUaDiNG � ��� / ��y, n� tian dapartment. ADDRE55 �d �S.rF,.ea� a�q/ho�u0 4A� oore n�u��r aTv -D•A/'11a�'-A�> �AenP �acnury CERTIFIGqTE OF EXEMPTION FROM WORKERS' SIZE OF lOT NOW ONB�LO � C OSSSST. ��7� C�{N�7.t� Q./� COMPENSATION INSURANCE (This saction need noi be complerod if the permit is for ona n55E550R hundrad dollars($100)or less.) TqACT BLOCK LOT NO. � µqp gppK pqGE pqRCE� TEI.'j USEZONE MAP I cenify that in the perfarmance of rha work for which thia OwNER� / Np. � n ryp �(as � permif ia lssued,I sholl nol employ ony penon in any monner qppRE55 7G'f L- )[//�'[L �JfJ17���0 `~� ���A� �' so of to become subjeci to 1Fie Workers'CompensaHon Lawa. / �! COND�TIONS � Dafe [IlY rI�V��� ZIP 94!�T Vi li NOTICE TO APPIICANT: If aher making�this Certificple of A��R� ��' DISTRICT GROUV ttPE FIRE 5 DBY O� EMe lion, ENGINEER DL�J NO. Z�G� �pµ�T ZINJE U mp you eheuld beeeme subject to fhe Workere' Z �_ � � W' Compenaotion provisirnn of rhe lobor Code,yo�must forlh- ,4Dp�� ` wllh comply with such provisiorre o� this permif sholl be �l STAi15TICAL CtA551FICATION . COf�O. tn deemed ravokad. �pryrytqRpR NO. ! '�� +f � � Z LICENSED CONTRACfORS DECtARATION p�. .. _ QA55 NO.��—�'1ELL UNITS � I hereby affirm thot I om litensed under provisiom of Chopter 9 ADORE55 Np, {commencing with Section 7W0)of Diviaion 3 of the 8usi�eu and �� SEWER MAP Profassiens Code,and my license is In full force ond affacf. CITY . CY?.55 �BK� � VALIDATION SCi.FT. NO.OF NO.OF CFK_CK LicenanNuml7er Lic.Class SIZF �� . STORffS � FAMIt1E5 ONE DESCRIPT�ON�WORK .��1ISIJX.L GL/f�GC.� NEW � VALUATION pO COnlrp�tOr �b O s /) �.�1./1• � _ A� 4 [/CJ �I am exempf undar Sec. C,�J�7� CGk�� p�,�,.- ALTER B.dP.C.for fhb reawn �!'s �PA�R ; 1 1 1 7.8 A . Date: USE OF /�C� DEMOI #� • • �L 3 EXISTING BLDG. arr��G�3 Signafure APttIUWT TEL. OWNER-BUILDER DECIARATION ��M P��JfF/��L�,�T NO. ` pA� � • '2�,b 3 I F�N�by offirm that 1 am saempt from ihe Contractor'a License �ppqE55�7�4Z��'Rf�/-� l�d-�����9�� • ' •2�.6.�,c` Law for ihe following rea�on(Seetion 7031.5,Business and FINAL,-y Professions Code): pRE ' � M� f Q 1 4-8% ❑ BUILDING I, 06 owner of the proparty, or my employees with qpDRE55 z 1 i 7.9 A wagen aa�heir sole compsnsotion,will do�he work and �he structure ia not intended or offered for wte(Section ����TY 7044,Business a�d Professions Code). MOVING IEL. �� � � • • � � I,as owner of the properfy,am e.clusively cantrading ONiRACTOR NO. with licensed mnhvctors to consn�ct The projecf(Sec- qDDRE55 ' • •4�'G� tion 7044,Business ond Professiona Code). - ,__ fr`' �„+ ., 4�J�U CONSTRUCTION IENDING AGENCY SEi BACK YARD HWY T�TAp p1P IINE WIDTH �y � �,t • • • I hereby aHirm tha�there is a conetrucfion landing ogency for FRONT I Q 1 4-8 7 the performonce of the wo�k for whith this permil is iesued F.L. (Sa[.3097,Civ.C.). SIOE V.L i �,•�J ~:'-i�`:.f�t Le�der's Nome—�1r�E -" ` F� LDMA Ref.M m Lender's Address�'L�' P.C.fee S Permit Fee � I certify tfrot I hove read this application and atote that ihe iu�ance Fea � tDMA PiC M , abova informotion is corroci.I ogree to comply wilh all County In�es�po�;on Fea ord�rwntee and 5 e ow ing t uilding consirucfion, Towl fee IDMq pxm.M a d her au�h ize representa o ihis Counry to enter � u on ih a ve- ionad pr ar inspection purpo s. 9 `d t '� SfE REVERSE FOR E]lRANATORY LAN6UAGE Signa�urc of App�icon�or Aqem pc�e Z o _ Q .. _. � . � _ �t G� � o H 1� Cr � ,, . -�-.o � a v T n � o. 9 ` -o ' o� ^`a' � � c o � '`y �! � . �QQ o �'� 1 F � �� J O O 3 3 O ', � - �O V'G � j �'7. O �c � t� A r . ' � n T tP O Q . ' � Q�p 0 p w �'. . N P ' Q cro 1. � j P � '�� O O �� N ?� b = � . �' � .a r- Q N : O t'7 'O � o. . '. •� Z. �1 mT. fio ti ? 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