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1180 S DIAMOND BAR (5)
. , WORKERS'COMPENSATION DECLARATION � � .;� ) . . . /� I hereby a«„m,ha�I hove a certificore o([onsenl lo sel( APPLICATION �FOR BUILDING- PERNIIT insure,or a cerrificote af Worken'Compensafian Insurance, � �� or a ceriifi2d copy thereof 5 t.3B00,Lab.C.) - � � � � � � � �z„��,,c,yq5�'s��� GOUNTY OF LOS ANGELES BWLDING AND SAFETY a�Y o. ompany�ioNA�cnvl0t✓ Ce.nfied copy�s hereby fum� eHl'2�/NS •�^ FOR APPLICANT TO Flll IN BUILDING pr � ��\ � � ADDRESS `� p \) {O�'C(\O �C Certified topy is filed wiih�he county building insPe�' � BU�IDING fion depa�tment. ADDRESS �f�O I� � ��y� �S hb liwnl��i( '(�jn" � � �ITY � f`�2 i1P / IOCAIITY � 1 Oot p CERTIFI ATE OF�EXEMPTIO FRO ORKERS' SIZF OF l0T . NOW ON�LOTS CRO5555T, � T��� COMPENSATION INSURqNCE � (This sedion need not be completed if the permfl is for one� . ? . ASSESSOR � h�ndred dolla�s(EI00)or less.) � TRACf BIOCK� LOT NO. MAP BOpC PAGE PAQCEL p TEL USE ZONE MP.P '.l I p �IGy� I cerlify thot�in ihe periormance of tha work for which Ihie OvmiER �t- NO. r.p, -�' V•f O .� permit is issued,I shell nof employ any person In ony manner qDDRE55 •O •� � OENDITIONS n' so os lo betome subject to rhe Wo�kers'Compensation Laws. p unL•A� ziv 4Q5 v Date � Applkant - .. �� � NOTICE TO APPLICANT: If, after making�fhis Certificale of ARLHiTECT OR T�• OISTRICT GROVP ivaE FleE PROCeSSED 6Y O E�emp�ion, you should become sub�etf to tha Worken' � FtuGfNEER NO. CONST: ZONE U Com ensation rovisions of tha Lobor Code, ov mus�forth- wilhPcomply w th such provisions or lhis permif sholl ba A�RE� 1E1. '? STALSOTIUt QASSIFI ON u APT. `CONDO. � decmed ravaked. COMRACTOR � N �y' N Z UCENSED CONTRACTORS DEQARATION ���, �/ QASS NO. ���WEtI.UNITS I hereby offirm thot I om li[ensed under provisions of Chop�er9 ADDRE55 � 2 Z.S� G NO. r`i�� � (commencing wifF Section 7000)a(Division 3 of tha Business and � � p�Q 3 p�, SEMlER MAP Proiessfons Code,and my license is in(ull force ond e8ect CiTv � ! M5��5 � gK �� . VALIOATION �-�� /� SO.F � NO.Of " NO.OF HECK � license Number , �� � �iC.C�O53'���� $IZE STORIES - FAMILIE$ �NE ' VALUATION � '_¢ � �3 � �ESCRIPTION OF WORK N� � Contracto ��,Y �-C-�Do} ApD ❑ s , ❑I am exemp�under See. Z L A��R � 3 3 6 fi 9 A 8.8P.C,for Ihia rca5on REPAIR � s � ��• •• •2 3 Dole: USE OF ��'1� t�' DEMOt ❑ I > � E%ISTING BLDG. �� L 4���� Slgnotora ,1 �r , � y J� v . OWNER-BUIIDER DECLARATION - A�P NTTT7OWR�ZD 2� DMA�7EOy��� I . DATE �l �(� r 1.2 3-8 7 1 he�eby affirm�hal I om ezempt from Ihe ControUor's Licensa � qODRESS ��J L s/ •L-� !l:�3 Law for the following reason(Section 7031.5,Bosiness and FINAL/L � Profetsions Code): � � NT . - . By (_�I . ❑ BUILDING �n���A I, as owner-of 1he property, or my employees with AD�aE55 ; woges as their sole compensation,wiil do the work and � - � --- - �� � the struclvre is not in�ended or offered for sola(SecHon � ����TM � �t 70e4,gusiness and Professians Coda). ^nOVm7G iEl. � . '! : ��/°���_ ❑ COMRAROR NO. � • � � I,os owner of the praperty,am azclu�ively tontraUing wffh licamed contraelors lo construcf the pro�ect(Sec- AD�RESS � � � 2� ��$7 �lon 7044,Bvsiness and Professiom Code). - CONSTRUCTION IENDING AGENCY�- � SE BACK YARD HVJY T�TApROP.UNE WIDTH I hareby a{iirm that�hera Is o construction lending agancy for frtONT the performnnce oi tha work(or which lhis permif ie iseuad. P.t. . - (Sec.3097,Civ.C.). �/ ^ SIDE : , �L1\ P.L. �'/ Lender's Name �r � � � ' T— / LDMA Ref.M � lender's Addrees - P.C.Fee f � �- permh Fse S � , I certify thal 1 hava reod this applimtion ond state that the. leivance Fen LDMA P/C N � � obove infarmotlon is corroct.I agree ro mmply with oil County Invesiigmion iae �7 - ordinanees ond Sfate laws relating fo building tonstruction, toial Fee � ) LDMo Perm.N � and herahy aWhoriza re esentutives of this Counry lo enter ve- ri d proper y for inspacl�on pvrposas. , /• � J SEE REVERSE FOR EX�LAHATORY IANGUFGE SignoMeol_ pplicontor�gen� po , � � -- � � . . _ � a . . . o � , , ` ._, ,y � . � _�, � , . . � T�- �' '� R O y � . , '� r n Q �O p- O . .r O � , . C � O N n v� �A ::J `'G ryU n1 �O O n F G n p ..�"r^� ' . 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