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0408A 0505A (6)
� WORKERS'COMPENSATION DECLARATION � � . . . .. ... .. . . -- -� --'---- ... ...-- .. - . . . I hereby affirm thot�hava a tertiiicate of�e�se�„o,e�f � APPLIC�ATION -FOR- BUILDING PERMIT � � insme,or a certifitate of Workers'Compensation Insurance, '� � or'a rertified c�the, ef(Sec.3800 .C.) (\�` COUNTY OF LOS.ANGELES ' � �� .� � BUILDING'AND SAFETY P�olicyNo.� 2��ompony `�Q . _... . BUILDING Certiiied mpy is hereby furnished. V FOR APP�ICANT TO FILI IN- - nDDREss �� (f� /� 8�'-+/ Certified copy is filed with tha tounry b�ilding inspec- BURDiNG tion deporimenL�� . � � � ADDRE55 ��Z �� � ��/ LOCALITY '�++•-/�'+'L -� NEAREST Dale Applicanl � � _ CITY \� ZIP CROSS ST. . CERTIFICATE Of EXEMPTION FROM WORKERS'- � S2E OF�OT PG� �� NOW ON�LOTS � MAP BOOK � PAGE PARCEL . COMPENSATION INSURANCE •�This section nead not ba tompleted if the permil is for one u5E ZONE h�nP /; hundred dollon(5100)or less.) � . TRACT BIOCK l0T NO. NO. �7'.�.7� � . . El. - e�� SPECIAL _. . 1- I certify that in tha pe�formance of the work for which this �NER � ��+ O. � CONDITIONS � perroh(5 issued,I shall not employ any person in ony monner ' ��-- ����-����� -� -�-�--��---� � DISTRICT GROUP iYPE FIRE PROCESSED 9Y 0 so as to become subjecl to the Workers'Compensation laws. aoDaE55 � / CONsi. ZONE (� V ._. �. ./ . . . tJx ._ C' Dote � ' ApplicoM � � ��Ty •, ZIP STATISTICAL QASSIFICA ON , APT. CONDO. O NOTICE TO APPLICANT: If, af�er mokin this-Cerfiflca�e of ARCHI7ECTOR TFL- _ V 9 FNGWEER 1-` �' ��NO. CV+SSNO.�DWELL.UNITS � Exempflon, you should become sub�ecf lo the Workers' Compensalion pravisions of 1he Labor Code,you mvst forth- ppDRESS SEWER hwv � , � . _. .. ._ ...._.. Z with comply with such provisions or ihis permil shall be � r deemed revoked. . . CONiRACTOR � ���' . NO. � -�--BK. PG, ---- � - VALIDATION - LICENSED CONTRACTORS DECLARATION^ � '�,`' ��� r I heraby affirm that I am licensed under provisions of Chopter 9 ADDRESS� 7-� ~ �F�J�I NO.�/5���� - VALUATION (commencing with Section 7000j af Divisfon 3 of�he Business and p�, ^-t ti C/� �Q�1 Q 8{� . Profassions Code,and my licensa is in full force and effec�. Crtv S� (}' QA55�'Ti� S 7GAQ� t � � w j7 �� - $Q.FT. NO.OF NO.OF CHECK . , �� �•• •Z.3 � O���r�I �iC.Class�� SIZE � STONIES FAMILIES ONE � License Nomber - � _ s ' 1 •{3fl25 ' ContraclorC � � Date�� DESCRI7TION OF WORK �I am eKempt vnder Sec. ' � ��C ` �� ADD ❑ . . .. . ��'L O�8�'�� . .. , ,l I� ALTER ❑ ' DATE` �7 �� P . 8.8P.C.for�hh reasan �- +—r�^ '"-�. . _... REPAIR � . . - �ote: USE OF /� . DEMOL ❑ -FINAL. . . . - . .. ' . E%ISTING BlIX'i. —7 BY $igna�ufe APPLICAM ;7 , TEL. � . . OWNER-BUILDER DECIARATION PRiNi �--r ISt NO. ' -"� I he�eby afiirm that I am examp�from the Cont�acbr's License `1,� � ' law for the following teason(Sectlon 7031.5,Business and � AODkE55 .Z r1/y5�� s \ - - - --� � � '- � '�-� - � �- 'Professione Coda): � . - PkeSeNr - � � � � I, as owner�o(1he� a er y P Y .. . BUILDI . � . ....... ........ . pr p ty,--arm em lo ees�with ADDRE55 " � wages os their sale compensation,will do the work and the structura is not finended or offared for sale(Section ��`��TM �� � � - . - � - -- � 7044,Business and Professions Code). lu�Ovin�c re�. �p 5 Q 5 A � I,as owner of the proper}y,am exclusively mnfrocting NTaAROR NO. . _ , � ' ... _._. .._. . .. .. . . . with licensad commctors to construcl tha project(Sec- ADDRESS �#� ��� �4'� �tion 7044,Business ond Pro(essions Code). . . . . . � REQUIRED TOTAL SETBACK FROM Ex15T. 4,��S�S O CONSTRUCTION LENDING AGENCY s�r gqCK YARD Hwr PROP.LINE WI�TH • . I hereby oifirm Ihat ihere is o conslruclion lending agency for . �fRONT � - - �� ���� - � � ,��,�5 5 5 0 c=i � the performonce of�ha work Tor which this pe�mit is issued P.i. , (Set.3097,Civ.C.J. � SIDE _ r.i. _ .._..- - I 2 1 3"83. . lender i Name )� Lender's Address P.C.Fee E -J�'^'� Permif Fee � I terfify 16a1 1 hava read this applitalion and stota thot fhe Is:uance Fee �O� . obove information Is cortett.I ogree to comply witb oll Couny Invas�igation Fee � _ , • ordinanros and State laws rblating to building eonslruction, � �- � Toral Fee � and hera o thorixe repr ntatives of Ihis Couny to enter upon th ob e-manfion roperty for Inspection vrp es. . - - � �� � � - � � � � � , �, � . SEE REVERSE FOR E%PLANATORY LIINGUAGE.. _ .,_. , .. . . .. . . '� 51 aWre of Appli �or Agent ta . ' .�� _ ' . Z O Gl . -n �: _fl 1-- � - -- o, (/t T� � Q �` �� 1! 1 1 � p o ,�a� � a7 ° �.� � �- `, ' , i ; r m ,� tn o m o x- ��C� ''�,�� n., ,� . � v o � ' 1 � ' � r p 7,t p U C, P 7 O ^}'�,.� �. 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