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HomeMy WebLinkAbout0996A WORKERS'COMPFNSATION nFCi n4qripN '�he.eby°"��m'h°„ h°°P°�e�°`;�°'e°`�°°se�"°se" APPLICAY10�1 FO� BUILDING PERMIT �� insure,or o cerY�ficote of Workers'Compensotion Insurance, !� or a ce�r�fied copy ihe�eof(Sec 3800,�ab.C.) COUNTY OF l05 ANGELES BVILDING AND SAFETY �� Po:licy No. Company . ❑ Ce�rified copy is ha�eby£omished FOR APPLICANT TO FILL IN Bu��o�NG-� �., y��r„ �. , `�? 1,'�r � � AD�RE55 1 .'� � � � ,.: '� s� «:r�� � Cerlified copy�s filed with the county building inspeo- AUILDING J �" p \r� \ tion depanrrient. no�REss �jG(U� l�j y��1}N /1� {�A.n .{) _,. 4` Date Applicant CITV���MORfn, {S.Iz��- ZIP ��/�gS LOCALIiY ,\ `- t -"''" }�.-,��_ � .�_1,..... CERTIFlCA�E OF EJ(EMPTION FROM WORKERS' NO.OP BI�GS. NEAREST � - � [ COMPENSATION INSURANCE SIZE OF LOi Now ON LOT CRO55 5T. ,�,��i ��c�„ f��\., ��-._(.�iJ\���\�\�� (This sr.ction need nol be completed if the permit is for ane a55ESSOR � �� hundred dollars($100)or iess.) TRACT B�OCK lOT NO. pppp gOOK PAGE PARCEL TE�� �60-��1 USE ZONE �P 9' 1 certify ihoi in ihe performonce of ihe work�for which ihis OwtieR 1..�5 tZ.. NO. NQ p., permi�is issued,I sholl not employ any person in any manner ,] �1 SPECIAI � � � so os to become subject to the Worke 'Com sation Laws. P.DDRESS Z �� �1� � I�h>� V�r��� CONDITIONS � Dote��.�q�t[� � CITY 'J(�MONi� p�1�- LIP -I�7f0 � �.�a Applicam �— ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPUCANT: If, after making this Ceriificote of fNGtnIEER �'+�� CONST ZONE '�y�j Ezempiion, you should bemme subje[t to fhe Workers' "- -,�-��'-�—; - .- - y � �� Compensat on provisions of Ihe Labar Code,you must forlh- ADDRE55 ��� ��� ---"=^— � ' �� � '� Y1'�.�3. U7 wifh mmply with such provisions or ihis permit sholl be A.1 TEL STATISTICAL CL455�PICA�ION APT. CQNDO. �� deemed revoked. CONTRAQOR �{/" t1� NO. Z'Z,:� r � LICENSED CONiRACTORS DECIARATION /� y� ���, / f CLA55 NO. "� � �WELL UNITS I hereby offirm ihat I om licensed under pro�isions of Chapter 9 ADDRE55 �� („�XI Q� y�-�M NO. �g J . . � (commencing with Seclion 7000)of Division 3 of the Business ond r� ��� SEWfR MAP PraSessions Code,and my license is in full force and effect. Ci7V {��I�fl�� CLASS C'3� Bx � VALIDATION SQ.FT. NO.OF NO.OF CHECK LicenseNumber 3q5+dSz Lic,.Class �� SIZE STORIES FAMIl1E5 ONE yAl11ATlON Con{ractor�/�W `d��S� Date"--R- � � _ DESCRIPTION OF WORK `'����d r NE'�'� a ; '"a.s-v. ^ ❑ 't\ ��� I�STRI� ���� O1IVIj" ADD �..+�-_'-� � I om exempt under Sec 5 ❑ ' - P _ ., ALTER B.BP.C.for�h�s reason i���:'u`�- REPAIR � Yinot' �L�„'d � ;,�.. � S Date: r��" USe oF oEnno� ❑ /'�" � ��.j.����� exisriN�e�o�. Signatu e ,y-_y� '�"`-'��`" .. APPLICANT TEL � FiNAL y�/i OWNER-BUIIDER DECIARATION �RiN71 NO. DATE���'���U d I hereby affirm ihat I am exempt from Ihe ConiraUo�s License Low for the following reason (Section 7031.5,Business and ADDRESS PINAL �f Professions Code): PR EN B1' ❑ eUiIDING . ' I, as owner of the property, oi my employees with ADORE55 wages as their sole mmpensation,wiil do the work and . the si�ucture is not intended or offered for sale(Sectian LOCALITY �_ � � �V G yry v� 7044,Business and Professions Cadej. MOVING 7EL . . ❑ CONTRACTOR NO. ' � n I,as owner of the property,am exdusively tonfracting �r� � e �e � with(itenzed coniractors�o wnsfrud ihe projecf(Seo- 6 pDDRE55 � tion 7044,8usinen and Professians Code). - � e o J(I,j>�� RE�UIRED TOiAt SETBACK � CONSTRUCTION LENDING AGENCY .9 SET BAtK YARO HWV pROP.LiNE WIDTH � -�- I hereby affirm iha�there is a wnstrutlion lending agency for FRONT e ° °7�''�`'t-�' tha performance of ihe work for which this permit is issued P.L . �� I �,�J (Sec.3047,Civ.C.). SIDE P.l. Lender's Nome - � �, P.G Fee$ Permil Fe¢ �`�`_�,1� LDMA Ref.M . Lender's Address ' , i certify ihat I h�ve read fhis application and state that the Issuonce Fee �t�� L�MA P/C N above informotion is correct.1 agree ro comply with aIl County Invesrgo+�an Pee y � f� ordinonces and Sfate laws reloting to boilding conslrudion, Totnl Fee ��` � �-�~��� LDMA Perm.# � and he eby authonze representatives of�his County to enter � � � upon t abov nfioned property 4or inspection purposes. . --�--�GIMi�M+w►"�"— .���-�7 SEE REVERSE FOR EXPiANA70RY�.'.NGUAGE � � .�y ' � Signafure of Applicant o�A9an* Date �_,._ _ .._ _ � � � ��� � -t � �+, � � < .. E . . .�.. . .__ .o_ �_. � _a �.._� .... i -. ...� � ��.. ,..,._ .�. � } � W � �s �' ' �. � g I � ��� 7 � �� f, X ' o f .� ,1. j �' : 3 � ?. I }' x__._ ;. < :;, � ��... � t � � � a .; � l � ✓ � { �� c� � ""€...u. 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