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1035A (5)
., � WORKERS'COMPENSATION DECLARATION � - � - � �� I hereby affirm fhat I have a certificate of-eonsem to=e�f -qp�..����T��� F-OR -:B[JI�LDIN�-G PE-RMI�T �i � insure,or n ce�lificate of-Worke�s'Compensation Insurance, � or a certified copy thereof�Sec.3800,Lab.C:) COUNTY Of LOS ANGELES BUILDING AND$AFETY PolicyNo. ComPany _ �- -.� .._ . ._._ -.. �Certified co is 6ereb furnished. � eUILDING :---� �� 0 PY Y FORAPPLICANT TO FfLL!N Aooaess f�`l Cerhfied copy is filed wifh ihe tounty buifding inspec- gUlL�ll�'. f���� � . �i � LJ tion departmeoL A�DRESS` . V;% $'� �i,�f. LOCALITY � � . � /�' `' NEAREST -.. g�. . , 1" � Date.� �Applicant CITY -r{�' (N, { A ZIP _ _ __..._ CROSS SL � .. .-y� . �� O -- CERTIFICATE OF EXEMPTION fRdM WORKERS' � NO.�OF BLDGS. �ASSESSOR - COMPENSATION INSURANCE . SIZE OF LOT NOW ON LOT MAP BOOK � -PAGE PARCEL (Thissection need not be-completed�if�the permit is forone = - �� �- �-- � ��75E-ZONE -� MAP � - � - �y hundred dollars($100)or less.) � . TRAQ� � BLOCK LOT O. �� -� NO ' � •-�`�� �- . . . . .._ . ..�. .' . TE �` SPECIAL -� �_ I certify that in ihe performance of ihe w fo whic �is �'NNER� .�Qr� . N ��` CONDITIONS__.. .-. . � p��mif is issuad,I shall not employ an e o`n' an' er � ol RICT .GROUP TYPE - FfRE � PROCESSED BY �r Y ADDRES - ,1 �.+ CONST Z so os to become su6je -b the Wo r y'm n p' ws. ,� . � \� � � i ��� � NOTICE APPCICANTt If, aft m kin �� � � w ` ` D41e �� ApPlico �- �'-� AIRCHITECT L' � � " ZIP T STATISTICAL Cl?�SIFICATION._ . � APT. CON00.� � 4� g iliis Cerhficate of �� � 1 l , - . �3 Exem tian, � ENGINE R � ' - �N CLASS NO. c.�.,. DWELL.UNITS_ � p �you shouid 6ecome sub'ect ta the Workers' +�-���g,p ^ / �:.�� lmpensafion provisions of fhe Lobor Code,you musi forfh- qDDRE55 �q.- 1�(,4' �/'� SEWER MAP ith comply with.such�provisions or�thispermit�shall be � � T - � deemed revoked. . - .. . CONTRAC70 ! . ' /� ' ... -aK.� PG, � 4ALIDATION � � LICENSED�ONTRACTORS DECLARATION ��� , � I hereby affirm ihat I am licensed under provisioni of Chapter 9 qoDRE55 ��� N VALUATION � � ([ommencing W ifh Secfion 7000)of D i5iah 3 of the Business and � � LIC. �v �7 � Profeuions Code,�and my license i in full force and eHecf. Cliv � ~_rQ�(,�/�.f�, c�A55 ls.-� / S �- ► � � 1, Sq.Ff. - NO.OF � � IVO.OF� -- CHECK LicenSe Number��•� n '�_Lic Class_�� SIZE � STORIES FAMILIES ONE � $ Coniractor -� d� " .. ^ ,pa�e `—�� DESCRIPTION OF.WORK '� °� r�j:,._ NEW ' �I am exempt under Sea� � . .. � "' '- � E--� ADD Q `.. . _- ... . .. . . B.&P.C.For this reason - . _ ACTER ❑� DA EL'F ��f'. �� , REPAIR . . Data: USE OF . DEMOI �FINAL.. . � . - . -��- �EXI4i1N6 BLOG. � - - ❑ 8 Signature ... . � . . ' � APP PR N ��y�"t'�^ , N. '" � OWNER BUILDER DECLARATION �� �u�A I hare6y affirm that I qm xempf from the Controctor's License - / ' � - Law for ihe following reason(Section 7031.5, Business and - . ��RESS . -��R-�-- - � �� � trF"� e � a �� � � � ProfessionsCode�: - , � �. . p SENT - - - � ❑ � � BUILDING ... . ... . . .....-_. .. . . I '�'��J EJ�rI�J I,.as owner of the property, or my employees with - ADpRESS-- ---- ---- ; . - wages as their sole compensation,will do the work and � - � .� �_�,yj(y 7�� the strotfure is not infended or dffered for sale(Section _.. �OCALITV _ - 7044,Business ond Professions Code). . - MOVWG � TEL Q�,.`( J»��U. . � I,as:owneF of ihe property,am exclusively toMracting � CONTRACTOR NO. wifh licensed confractors'to consfruct ihe project(Sec- q6DRE55 tion 7pq4,Business and Professions Code). � REQUIREO TOTAL SETBACK FRpM EKIST. CONSTRUCTION LENDING AGENCY SET BqcK YARD Hwv pROP.uNE wioiH- ► I hereby affirm ihafihere is a ianstrudion lending agency for �FRONi � ihe performance ot the work for which ihis permi�is issued p.L.� (Sec.3097,Civ.£.). � - SItlE - . .. . �P:L: .. . . . . Lander's Name . - � . . � - . - .. _ . . . . - Lender's Address �:P.C.Fee$ � Pe�mit Fee . e I certify thal�l have read this application ond state that fhe Isso ce Fee � `� . - an � a6ove informafion is correct I agre to tomply wi}h.o11 CouMy In estigation Pee _ l _ _ � � ordinances nd� �f,9 I ws;fel �to boildmg constru[iion,� � ----- - -- --- � ---- i and h qy. 9riz �es t'es o#1his�County fo enter Total Fee "��-� � �p eY .�e`m i e rFp-FdFPi`nspect on p� _ .. :.. .. . .. . � . . . . . _ . � � //p� ^`�- SEE REVERSE POR E%pLANA70RY LANGUAGE - Signature of Appl'mnt or Ageni " pnte � . . �.. . . . � . .�a r � 4 �� ("p.i — rm -+� G. � Us:O p o fB'6 m�a� '�'u'i �P �, Q �. .., . 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