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HomeMy WebLinkAbout0298A 5764B 0299 (4) ,, » WORKERS'COMPENSATION DECLARATION /,J)J, �j (jV �`�`i��S , > � I hereby affirm that i have a certifiwte nf consen�to saif APPLIC�.T,I FQR BUILDING PERMIT insure,or a tertificate of Workers'Compenwtion Insurance, Q�_ or a cerrified copy rheroof�Sec.3800,tab.C.) _ S'„OUNiY Of LOS ANGELES BUILDING AND SAFETY � Policy Na. Gompany � Certified copy is hereby furnished. BunD�NG h ` FOR,APP ICANT FILL I A�R l� Cerlified capy ie filed with fha tounly 6uilding insper BUILDING tion eport ent.� aooRE "rDale � PPlican� Clir ,- P.� t ' . , IOCAl1TY �TIFICA E OF�xEMPT10N FROM WORKERS' ��OF 61OG5_ _A� NEARESl • COMPfNSAT�ON INSURANCE SIZE OF t0T NOW ON lOT V CRO55 ST. (Thic saction na�d nol be compleled iE Ihe permit is for one TRAQ BIOCK � LO7 NO. S� �E � hundred doilars($100)or less.) �� hWP BOOK PAGE PARCEI - - � ' TEt. USE ZONE � MAP 1 cert'rfy that in the performpnce of the work for which this OWNER NO, � � 3 � ! permit is iesued,I stwll nm employ any parson in ony monner - �[�� �/ yEqq� � so as fo betome Subjecl b fhe Workers'Compensation taws. NDORE55 �� �/C�/ ���/ ���T�� (� �� � , � •' Applicant C�Tv � }� �i�i z�P� � U ' ARCMIIECL lEl:.1 � � JICi i0 AP�LICANT: If, ofler making�thie Certificate of �-P� �I� I TRIR GROUP tYPE FIRE SSEDBY O � '� ENGINEER �/ nplion, you should batome su6jed to Ihe�Worker� /) � "/✓ CONS N� ZONE � F- .npemation p�ovisioro of the Labor Coda,You must forth- ADDRE55 . - Q/{/ � /tl � / � Q'2 ��( � W �, with comply wilh such provisions or thia permit shalt be 1f � daemed revoked. CON7RACfOR(/ .- . Nl. _ -- STATISfICAI CVSSIFIGF,TION qpT. Cqdpp. z � LICENSfU CONiRnCTORS UEUARATION — - aass rro.�L.DWELL.UNITS � 1 hereby affirm tFwt l am licensed under proYisions of Chapter 9 AobRE55. '��S�QA- �� pp. 't (commencing with Section 70WJ of Division 3 of the Busineaa and .. � � �K . SEWER AAAP k Profassions code,ond my IiCenSB is in full fortB ond eff9c1. CITV~ • �� �� . � r SQ. NO.OF'. .�f N0.OF ... . CHECK, 8N. PG. YALIDATION j License Number--�Ca Class� SIZE �STORIES�. 7^. FAMILI . ONE � •�. _ YALUATION #:Q 2�i��3 . Conlroclo � �w te DESCRIFTION Of WORK �W'-� • i ❑I am eKempt�nder Sea ,__-��' � � • �.• � s � ��L Q 7 Q 2 5 � AL7ER . �,( �/ � 8.&P.C.fa this�eoson r , REPaIR f s/� 7'�Q� � •F V%�"�-r'`-x oo� F%59TNG BLDG. DEMOL p 0 2 3 0—8 7 1 , Sianafure APVLiCANT . y�'r TEL FiIiAL OWNER-BUILDER DECIARATION PR��`�T Iy N�NO. - p I heraby affirm tFwf I am exampt from the Contractor i License �* �j�} ,/� / DATE ��"/���9 �� Eaw!or Ihe following reaaon(Sstlion 7031.5,Bucineu ond ADORE55 �IJ ��^^���/�� l Ip��� fl�lAJi", �-�y 'F,/1=� ��Fessions Code): �i�� _ _ _ , . ' q � �f �• . �,;' � �� '- as owner of fhe property, or my employees with AD�RFSS , ` '-" T vi�gay as�hei�sole compensation,wiil do the wprt and ��D� � the structure is not intended or offered for sale(Section ��+��n' � . � G�'� ..:�� 7W4,Busineu and Profeuiona Code). MpVING TEL. , � � 1,os owner of the property,om exclusively conhacting CONTRACTOR NO. `�� „:,,. .: with Ilcensed contratlorl to conatruct iha'project(Seo- qODRE55 I ��� � ��� ;—•''1 tion 7044,Business ond Professions Cods. � � � E UIREO TO AL BA K l CONSTRUCTION IENDING AGENCY SET BACK YARD MWY pqpp,��NE WIDTN I 1 hereby affirm Ihat Ihere is a construclion iending ogency for fRONi 7�s0�8 7 1he perfwmanee oF the work for whith thia psrmie is�iaued -- -p,l. � � .,6��,�.p�p (56C.3097,Civ.G.)• SIDE � ��� ri V H a!U W i P.�. . D�99 lender's Name .J D_ IDMA Ref.k Lander's Addrau P.C:Fe�f . Permlt Fee��-/ � ,Z' � 1 certify tba�1 Fwve read this applim�ion ond sta�e dw�the - /� Iseuance Fee }' �..� LDMA P/C N � �aQd� �_ o6ove informofion is correct.1 oyree to comply with oll County investiqatio Fee / ordinances and Stats bws ralaling to 6uilding conslN[tion, s,�+-'^' �`Q L�I ,�.�� IDMq parm.M and he�eby authorize represen�ulives of this County fo eNer - Total Fee �� upon 9 obovs-mrntarwd prqperty fw iospection aoa. -.' - -- - � - . . . . , �`�O^ � ..J__ -- -- -- - � a/ . �iC.x�J SFE REVERSE iOR FXPUNATQRY LANfAIAGE.�'�J_ _ __. .. . . . . .._ _: _.. _.._.. .. .__ _ .. _.. _, Siqnrnun of Applimm w Aqel ' __._... . ., . _ . . .. .. .. _ . � � � . �''� \ � ` � \ J ` .� .c " � � �' ;.a "' _ ,.._.. � * o m � � �' c " � � � � «�' `s .� �* v. k�-.�,� � '�'S i , � G � J 'y"" N f. . d �' � h V.. ��T '� .. ;,� h�% � r✓ N 'n G. .�.a � t 1\� a !h �y> . • ,c '4 x� >s ' � � o .. �•" co 3 ,� 4, 't � ��;. � 6 o M.�c.�r� 'w M;r s � m a�=' c.,� ; Q F"�.. � r- :S �..`., e�" �o � ;, 'r: _ -- k �_ � y s-;.� c.- O �, �+J� t. �"' 's;�., a e; .4�h�,:'�t'a 4 . .,, :.�' 'Z � .e �r ` � ~c..`+���. =-..- :,s�,� �,i� _' :y � ` u ��� '' c � .�� $ p;~F��_^�rG w„� �a s�'V� x,.y� .;S`,��� °'-�^s �� � p � c� C a � �r r µ-r.. _ ;. �v:..i F M» � � � � c.s,.''y•.,;:i:"' t o �'.: *" -- � iJ � �� � : �-� �.�� r.� � _ T -� o _ � � _ ���.� � . � ���. m � � , nc � '� .s y t �-s .+�A� T U �'"` ^ � � 4 c `. oM1�.'M �� �P � ` � � f" .'�h, ��l:'J;. � .�'.+..^ ¢ "`�r. �Y � �� ",,�+•�' '�,�, "'�.. ^ y'4 d J � �:'�' « s. 6' Z J� y� ���..`� i� � C �: ,'. v. !, � C� C,,,,"'3 a. ��S-� �� .� �T$L" � O �C.y, � � � � �i ` '.. - c. �Ys � o - _ � F r p� � _ c,� � C c, G Q * .ay y "G � �� Q+� v (� � x, ^ � i,��¢'=,'�'�' �,-�"�� c-s o c c � �.a �s'� s �a c� � � � ` � `�' ' t c ? o-� x '",'; a %' � �V-y' '�' ` �,��= �`^ 4-G�� ?a = „ t `a� � U a � " " ^ c� \ :�. rn E'• ' � � �:-� � -- � s E �o ;. � o -:d c =� c d M� c.,= �. � � j .:3 '3 j � � '3 M :..'�'.¢.� t v N �.� � � �,'- ,,,,_ ; C m :. _ 'y � l � � -* � y� � � ` � J � a � o �. � �' y � � � i .i ` G.r..n.".. 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