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HomeMy WebLinkAbout1254A 3338A 3339A (6) , ~ WORKERS'COMPENSATION DECLARATION � - � � � � � � � � � � � - � �- � �� � /� I h�reby afFirm that I have a terlificate of consent fo Self �pp��CATIO�V �FOR� BUILDING PERMIT -� � ' ins�re,or a cer�ilicate of Workers'Compensatian Insurance, L�� . or•o certif'ed'py thereof�Sec.3800,tob.C�./ - � COUNiY OF LOS ANGELES �BUILDING AND SAFETY co�r�o���f"pO 3co���r�dr;.,....� o. � Certiiied copy'is hereby fumished. FOR APPUCANT TO FILL IN eui�DiNG ��- f� ADDRESS ./�• (�L i)a�' ` (� Cer�ified capy i�filed with tha counry bvilding' pec- BUaDiNG p tion d pa menL nDoeE55 J`�5� � ����ub � 'lL(�� y -�Kda1e//r � APPlicon ~ CITY�JIA N �n` iIP �' �l�V IOCAUTY � h� C c..Y ✓7J�-1� F CE IFICATE OF ExEMPTION FR WORKERS' � � .NO.OF BtDGS. NEAREST . f COMPENSATION INS ANCE . 512E OF l0T NOW ON LOT N�� CROSS ST. (T is section need nm be compleled if the permil is for one -- - TRACT Za o`�J BLOGK �'� LOT NO.O � �ESSOR � ' hundred dollars(5100)or less.) , MAP BOOK GAGE PARCEL TEI. 3 3 USE ZONE �N+P � OWNER - Z � NO. � � 3 I ce�tify thaf�in�he per(ormance of the work for which ihis - ( `4„r NO. � Z. �'$ permif is issued,I sholl n0�employ any person in ony manner qDDRE55 Z ���Q .Pk�rrr{�-rN�,2�, y SPECIAL • O so os to become subjecr ro the Worken'Compensa�ion laws. (� q cONoinONS Date � Applfcant- - . CIiY k,_J � Z�P l (7�0 - � � QTICE TO APPUCANT: If, of�er mokin �this Certificate of /RCNi1ECT0R�T�I r TEL p D6TRiCT GROUP ryPE fiRE �ROCESSEDBY kmplion,'you should become sobject fo--Iha Workers' ENGiNEER J L'C't {`��� NO. o ^���� �p�.7�T � ZONE � _dmpensol(on provisions of Iha lobo�Code,you must(orth- ADORE55 (36�1�y1,�ivC4�� t+ �� ��' 1 Q �irZ" � W with comply with such provisions or this permit shall ba . �TEL. � STATIS71CAl QASSIFICATIONJ APi. C DO. fap deemed revoked. , - COHiRnCtO t S��'�io fJ!/&r-� NO. Z LICENSED CONTRACTORS DECLARATION� ,�+ �p�.�� ���,p3q,�,Z,3o QA55 NO. � DWELL UNiTS - - — I hereby otfirm thal I am litensed under provisions of Chapler 9 ADDRE55 J�'06 � NO,� ��R�P � (commencing wi�h$ecrion 7000)of Division 3 of the Business ond . , � Professlonz Code,and my Ilcense is In full force and effecf. CiTY M oN�G��i�- CtA55 � .-__ ..... .. .. . . .. yALIDAT�OH � 1h�� � SQ. NO.OF NO.OF CHECK BK.--..---�',-�--....-. Licensa Number '�3�I Z'23p Lie.Class " St2E STORiES� FAMIt1E5 � ONE 'tI C VALUATION CoMratlor'w I D�S .' Dale o �I $� �-- � �ESGRIPTION OF WORK . . . ... N�. .� s� "" . ❑1 am e=empt onder Sec. �N�� l�Lf (.�,Ktp�,�/ ADD , :_� 2�4 A � ALTER B.BP.C.for rhis reason l/,�F/,j�02 3�3 3of so6 Q� S �:�� 1_ ` �1 � •! •2 3 . . .. . -Date: H �i I 6� USE OF l�./+ �(/7ZJ � �, � FXISTING BLOG.D�� �`+ DEMOL ❑ I •4 3 a 5� .. Slenefure �T1Lf� '�Q"""`�' . ' . . AVPIICANT /J� �,` - TEL. . OWNE -BUIIDER OECIARATION PRIM �^��K"'� No. ^300! pATE� � �4 3 3.5 0� . 1 hereby aifirm that I am ezempl f�om�ha Contracror's Litense /��,i���f���/ -��� � t��� � law for�he follawing�eoson(Sectian 7031.5, Business and aDDaE��C�/�"� �/ FINAL /�� ' 0 g J� `�7 ��P.oiessions Code): - ��- � � � paEseNr BY � �l..rGCti-- � � :'3 3 3.8 A ^-� BWIDiNG .. . . . . . .. , �� I, as owner ot�ha property, or my employees with ADDRE55 � �2.j � wnnrs ns thair snlw tompPnsntlon;will do}hw wnh pnrj � n• �• - the strocraro is not intended or offered for sole�Sec�ion ����TY � 704d,Business and Professions Code�. � - - ��- MOVING � - TEL.- - . I s.� � Cl O'J � I,os owner of the prapeny,am ezclusively comracting CONTRnROR NO. • •1 , �O 3 U with litensed conNottors�o conshvtt 1he project(Seo- � ADDRE55 � � � � �� - --- � � �- tlon 70aa,Business ond Professions Code). ' I �,�6�$7 - � � CONSTRUCT�ON LENDING AGENCY - � - RE�uieEO fOTAt SEiBACK F i ' � � � � � � , SET BAIX YARD HWV PROP.IINE WIOTN ^ , 1 hereby oiiirm�hat ihere is a tonstrutlion lending ogency for feONi ty�� 0 �,�_ �� �he performanca of the work tor which this permil ie issued P.t.. � r '3 3 3 9 A ($ec.3097,Civ.C.). . . . . . SIDE `. ." •` , P.L. lende�'s Nama �� � � ���� • ��� � � �^'� IOMA Ref.N Lender's Address � � P.C.Fee S � V Permit Fee '�� -�� � •6 5 7.0 0� , I tertlfy thal I hova reod�his oppllcalion and slate thaf,the , I�1���� la�van<e Fee ���� iDMA P/C N � •.a�:J 7��v � obove information Is wrrecf.I agree to camply wi�h all Counry i�„e�tigaron Fee '� ordinantes and S�aro laws re ng to 6uilding tonstruttion, ' Tom�Fee . �•Q� IDAAP,Perm.k. � },O 6�fj'] �, � ond hereby avthorize repre nlafives of this Coon to enter � � � , upon obo -me tione pr erty for inspectio pory ees. - � , . �� � 3� � fEE REVEKE FOR El(►LANATORY LANGUAGE Signa�ure of Ap �con�or Agen1 . po�e. . . ... .. . . . . . . . . . . . .. . .. . . � � .-. e . .�. _n T '''. . �.. _..;_ •1"__ p2 O m "' V' � V+C � � O tD� A � O � �'r Q ^ i '�� ° � s-. � �D 3 'v � �° F � ^ o . m " ,°o � `� s n ' f m o o � I ��� iO � � � o D � � � "_ `p n : �� "p � �: D'. : o ; Y' � - f' 9 c �� (�� o _ v = � � Z '� � • '0 1 ,�o p o = v l tt�� � of _N °" o . °� � �° . � % � o v3 - o � - . � < o .� o 0 3 c � ' '� , " n ' J� � o � g c` -, o o � - � 'm - ro � o m . ;� m , o . a �� �-^_ ? � — . . a� � , o . , ,. � � � A _ � � � D [i ' � � 2 � • I ' N �' � O � Z ..� Cr ° ; ,� ° O `< <,n ° � � , �. .�' ` D r. � J ' �° - m v . � � ,. , � , _ t . �.r �. e ; _ � � i ' - Z 0. 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