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1616A 3189A (9)
. WORKERS'COMPENSATION DECIARATIOM� '� : � ��� � �� � 1 hereby oi(irm that I have a cerrifimte.of�o�,e��,o,e�f �� -.� � �— ��qpp�,�CATION �FOR��BUILDING PERMIT � insure,or a certificole of Workeri Compensation Insurance, , or a certitie copy there�o�f{�fSet.3600,lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Polity�.�77�`� 'Cbmpony�TtYF1.�/�C?� � ��^ O . .. . . BUItDING 1� � A� �� Cenified copy is hereby fumished. FOR APPLICANT TO FILL IN ADDRES$ �t' �U r � Certified copy is filed with t cou ly building inspec- �` � BUiLDiNG n lion cjepart�nt�_, � �l ADDRE55 �� 0 AL(SC,' �� � ` � ��'� 9/7l� ' '�s�c�.c4 N�-- Date pplicaN � �� �iT1'� ZiP tOfALITV , t CERl ICATE OF EXEMPTION FROM WORKERS' � � ✓- � . NO.OF eLOGS. NEAREST , � � COMPENSATION INSURANCE- ��� SIZE OF LOT NOW ON lOT CRO55 5T.��-�� (This seclion need not be tomplefed if the permil is(or one .. . n55E5SOR hundred dollors(5100)or less.) TRACT BL K ' tOT .- � MqP BOOK PAGE PARCEL TEL. � I tertify tha�in the performonce of the work for which this � OWNER� � NO. '�// -3 ��Z�NE ppP '� '.��S parmit is iszued,I shoil not employ any peison in ony manner n e_M SPECiAt � �� so as to become s�bject to Ihe W s'Co nsatlon s. /DDRE55 O- A��11��D�� CONDITIONS 0 Dara Applicanl CITY 1�A) B��- ZIP �7�1 � NOTIC TO PPLICANT: If, ofter moking�lhi5 Certliicate of ARCHITECTOR TEL. DISTRICT GROUP NPE FIRE PROCESSEDBV O ENGINEER NO. � �p�KT ZONE (''� �"" � Exemption,- you shou�d become eubjetl to the Workers' - - 1 (� � C\\�`� W Compensa�ion provisions of tha labor Coda,you must forlh- qo�RE55 l0 . v � , �"� with camply wifh such provtsions or-this permit shall be .._ . . _ � hi, � STATISTICAlClA55 �UTION APT. CONDO. fp deemed revakad. � . �ONTRACTOR ( t S C O. ? Z IiCENSED CONTRACTORS DECIARATION . . uC. CiASS NO.-� '2 DWEtC UNITS I hereby aHirm that 1 am limnsed under proviiions af Chapter 9 ADDRESSJyL 1�� F. NO. �i O� yy,�R MAP � � (commendng with Setlion 7000)of Division 3 of the Business and �i�. � Profesfion5 Code,end my Iicensa h in full force ond eHect. d7Y�o. nib L � � CLA55 g- -�----�BK.----�,--��--�------� ------�----VALIDATION � � - S�.iT. NO.OF Np,OF CHECK liceMe Numbe��o 90nn LiC.CIo55� S�ZE � STORIES FAMILIES � ONE . VALUATION Conlrocrov�l/1R`/M.LN/!�7✓s ir�Dnte^5—u� OESCRIPTION Of WORK P - .fT1�6- Nfl'�' a l^ ADD = �� �� � �I am exempt�nder Sac. � /^�� 1� �� � AITER 8.8P.C.for this reason . , . �rlNlS�'U � /�✓ ��ET//�'f��^" EPAIR ❑ � S .- .. . . . .. Z 1 6 1.6 A SE OF � o �. . .a�a�� . Da1e: E%ISTING BLDG ��'a . . . . . $i nalVre - � - APRICANT - i- TEL FINAL I � •7 Q� �J 9 OWNER-9UIlDERDECLARATION artiNt /�!� piJS SdG. No. o'!/ pAT 2_Z/� T .I here6y aiiirm thaf I am exemp�from�he Contractor's litensa - ` p ��"""`�r � . ., • • �7 Q� J u Low for the following reason(Section 7071.5,Business and ADDRESS y6 No UIQ�rM�D� /7 � flNAL . , - Professions Coda); �� � BUILDING BY � -0 9.1 5—8 S � I,os owner of the p�operly, or my employees with noDRE55 . woges as rFeir sole compensotion,will do tne work and : tha struct�re Is not Intended or offered for sole(Section LOUIiT�' . 7044,B�siness and Prafessions CodeJ. � - MOVING�� � � � h�• � - � - -� - O �ONTRAROR ND.. . . . .. . . . . . I,as owner of the propeny,am ezcl�sively contracting - with licensed contraclors to mnslrvtf ihe project($ec-�� ADDRESS�- - � tion 7044,Business and Professio�s Coda). RE�UIRED TOiAL SETBACK F i - - CONSTRUCTION IENDING AGENCY ���� � � SET BnCK - yARD HwY PROP.lwE WiDiH � - � � ��� a(�� I hereby affirm tha��hera is a conelruc�ion lending agency for fRONi the performance of Ihe wark for which lhis permit is issued . P.L. - � _ - � � _ ��,� . . 1 (Se[.3097,Civ.C.). SIDE � � .. r.�. f •�9aG0 lender's Name f-� LDMA Ref.N i - � � P.0 Fee S � \ Permi�Fee ��•J�- •♦ •C j V��r : i��a�rs a,da,�ss y 1 certify that I have reed Ih15 appltcatfon and stata ihot tha . _ . Issuonce Fee ��..� LDMA P/C N � �,� �j—F}tj obove information is torrecL I agree to comply with oll Co�nry � in.esrga�ion fee q�j ordinances ond S�ore lows relaling to 6vilding tonslructfon, Total Fee / a� Q� LDMA Pe�m.il � - on -hereby authorize represemotives o(this Counry to enter � on th abo • e� d pro�(or Inspectlon purpoxs. _ - , � /� SEE REVERSE FOR EX►IANATORY LANGUAGF L SiqnoNre of Appiicont or Agent Do e . . . . . .. - . . . . . � ' � ., -i O p = j ' Q '7" . �. '�^ ry � �o n� o m � + ,.o �c. c ,; i . o ° o � o ° ° , a 'e � -• r m � U+ � �O � F O n D . �N •�A. ��U U Q n q��. . . .n n o a � o ° � o'-o � c .� o c �s = .� , , _ , T o o T � 3 � a C � a � ���: n� ° i 7 �-' n � � ' ` a ;p � ^ C S � • � 6 0 ^ � 'C '. 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