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_ � � ' ,�WORKERS'COMPENSATION DECIARATION ���(/(/�"�'.'Y •�'I+ereby-affirm tha�I hove a cer�ifimte et�o�=en,�o,e,� ��� qpp� ATIQN FOR� BUILDING ERMIT � insure,or a cerlifico�e o1 Workeri Compensation Insurance, � or c�r-�ified copy ihereof�Sec. 8 ,Lab.C'.l . � po�y�N�✓(r°ZO(b����,fy� ��/�}-I CG , COUNTY OF LOS ANGELES BUILDING AND SAFETY � Cer�ified copy is hereby fumtshed. FOR APPLICANT TO FILL IN a oaEss a .S� d`Y.�-��,-wr�.. � � CeHiiied copy ie filed wilh 1he toanfy 6ullding inspec• BURDiNG�7 �MO�p �.t�7 g��D ,. ' iian department. ���ClL AD�RESS"4 � � H oo�a��Applfca�r�'' Cn�ST�UC�o�'S arr pIAMoNA BARzir i iT CFRiIFICATE OF EXEMPTION FROM WORKERS' � 1 NO OF BLDGS. nl � � �COMPENSATION INSURANGE s�ze oF�o,193d X 57Q0 NOW ON LOT � CRO '(This section need not be completed if the permit is fo�one �� TRACT Z Jr9S ��IC� ' LOT NO.Id� Q ASSE R hundred dollars�$100)or less.) AMP BOOK PAGE PA El �" TEL. I USE ZpNE Nu1F ^2� �certify ihot�in the performonce of tha work for whlch lhis OWNER� i GQ IC{� �d��s NO. td0. -� J } permit is issued,I shall not employ ony penon in any manner • � ' 1 C.. �^ � SVECiaL . d� so as to become sub�ect to tha Workers'Compansotion Laws. ADDRESS� � Q L uiJ I CON�ITIONS �;. Dote Applimnt � . pTY F�CC;O �QG � ZIP OZ ! �i � TI�E TO APPUCANT: I!, oiler making-thiz Certi(icate af AR�HITECTOR-{(- TE�. _ ��., iCT GRDUP ttPE FBE OCESSEp BY O ENGINEE2 1�10 QS Z NO. CONST. ZON 1 U � �mptian, you should bemma subject.to the Workers' Compensotion provisions of the Lobor Code,you m�st forth- qooRE55 y !/an�fu s �L..s-�• 9�yo ,J� � ��� a wl�h comply with such provisions or this perm�t shell be /1 �y-p1 L � STATISTIUL QASSIFjCAT ON / AP. NDo, cn deemed revoked. GONTRACTOR 1�� �l�"��C�O. � �� ' � Z UCENSED CONTRACTORS DECLARATION h�7 M �1 rt�- _f ��}��, /� (1A55 NO.�DWELL.UNITS � � 1 hereby offirm�ha�1 am licensed under provisions of Chopter 9 ADDRESSo(/�6i(/S. l(/GJl�p.lU�WO.:S"+��-3 �� (tommentin "Ih$ection 7000 of Divisfon 3 of iha Bus�ness and �)��j^,'f, p �/�' p�r�. ��R�'P ` Professlons Code,and my license is in foll force and eHect. "� CIN NTl�C:f�U / 1-�S Ce/�y�SCW55 B � , BK. �. VALIDATION y"� 50,FL NO.OF �.�p,OF � CHECK � ��� license Nomber s"�'`�� lia Closi � SIZE L3 Odfl SiORIES -� - FAMIUES ONE � �- �JPr�� ' . N� VALUATION �o - \ �QJ►IS f�/t(��$ L�_�d^c?�, DESCRI7TION OF WORK �Cl1 YYlO t0(i �Controctor ote /fi App � S � p00:O�0 � I❑I am exempt under Sec. IG r � AITER � !s � � � B,SP.C.for this reoson '• REPaiR ❑ � USE OF ��w, - Date: E%ISTING BLDG. Sl"7�PS-ST��� DEMOL ❑ . � $ignature . . APP�IG4NT TEI. j^ FINAI n ��, J J'�n C OWNER-BUILDER DECLARATION 7RINT)�OVNQS Ur�PS NO.� -�� DATE '�3��7(' � _ =3 � I hereby afiirm thal I am exempl from the Controctar's License � pDDRE55 ��-J U/7 L) S/��ZI7 S-�•(At' FINAL { , •h •�' � Law for the foltowing reason(Section 7031.5,Business and , I 2�-.���J � Profe3Si0n5 COde�: � � � � PRE EN BY .L�?i:l,�� �.? BURDING ' I, as owne�of the property, or my employees wilh nDDRESS , ; +�wo9es os fhelr so�e tompensatlon,will do the work and � � � � � � � �.J O-��� _ ..the strocfura is not intanded or oHered(or sale(Sectlon ����Tr � � 7044,Business and Professions Code). . MOVING TEL. � I,as owner of tha properly,am eKclusively contwcting CONTRnROR NO. wl�h Itcensed cantmctors to mns�ruct tha proiecf(Seo- pDDRE55 � � � Iton 7044,Business and Professions Code). - REQUIRED TOTAL SETBACK :'S 2 9.9 A CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE W��TH I hereby affirm�hat there is a tonstruction lending agancy for fRONT � Ihe performonce of the work for which ihis permit is issued P.L. � �• • • e s � (Sec.3097,Civ.C.�. SIDE P.L. tender'e Name (3.2�l 3 G 0 LDAM Rei.f1 Lender'e Address P.C.Fee mh Fee z 32•.Sa ; •3 2 4:i�O<{ . I cenify that I have�ead this application and slafa fhat 1ha Issuonce Fee �0•J " LDMA P/C N � Q�j,3� -�C obove info�mation is correct.I ogree ro mmply wi�h all Coanfy Investigallon Fee �/ ,.] ordinonces and Slafe s ralating ro building eomlrucllon, Total Fee ��`1`�N � I�MA perm.M � � and hereby thor r resentatives of thie Coonty to anter - � - - - upon ihe ve• e ' n prop�rly for inspetlion purposes. ��(/ �• /`q�,�t+..-� � 3"� SEE RFVFRSE FOR F%�IANATORY IANGUAGW '2SJ ' /� Siqnat� ot App" nt or Agenl poro-. - - . � � Z o. 0 ; - � _�- � � r'� . � _ `' rJ �J • G� � � ° = . �',• U c � ? . � fna 10 °' � t� �° d n b •+. ; `� � �o 0 0 ° n; ,°o .� �� v � a•'i O 3 � n O n � ' F d n � Q O 3 C o . 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