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HomeMy WebLinkAbout1364A � . WORKERS'COMPENSATION DECLARATION � 1 hereby aff��m �ha� � ho�e a�e�f�f��a,e of�o�se�,,a=e�f APPLICATION FOR BUILDING PERMIT insure,or a certificate of Workers'Compenstion Insurance,or a ceriified copy thereof(Sec.3800,��b.C) COUNTY�F LOS ANGELES BUILDING AND SAFETY PolicyNo. Company � � Certified mpy is hereby tur��shed. FOR APPLICANT TO FILL IN ADDRESS �.�v�cJ ��--C��� � Certified copy is filed wifh the county building inspeo- ew�DiNG_ ��;� ����_ . tion depariment. ADDRESS � �(�C�����G._,] LOCALITY NEARESi '1c�l� _ Date Applicen! CITY � � 71P � CROSSST. � ���1 CERTIFICAiE OF EXEMPi ION FROM WORKERS' NO.OF eL�Gs. A55FSSOR COMPENSATION INSURANCE SIZE OF LOi NOW ON LOT � MAP BOOK PAGE PARCEL (This sectian need noi be wmpleted if the permi�is for one USE ZONE MAP _ hundred dollars($l OQj or less.) TRACT BLOCK Lo7 NO. �+ No. �� � � Y (1,� �('' b� ` TEI ��l� n SPECIAL a I cerfify that in the performance�of the work tor which ihis OWNER y� �- E. �} yiJ�.1.:`J NO.��'-� �.]� �� �a"�1Q CONDITIONS o permll is issued,1 shall not empioy any person in any manner t.� UISTRICT GROUP TVOp��— fIRE PROCESSEI7 BY V so as to 6ecome subjec�to ihe Workers'Compensation Laws. ADDRE55 ��(V�\,�L.- � � � � p�- 0 �ate ApplicanY C�Tv Z�P STATISTICAL CiA551FICATION � APT_ CONDO. V NOTICE TO APPLICANT� If, after making ihis Certifimte of � AkCHi7EQ0 . � e TEL ^-�� b,` ya Ezemption, you should become subject fo fhe Workers' ENGINEER � �: 4. , `v NO.�`l���4 CLASS NO. DWELL UNITS� � Compensalion prcvisions of fhe Labor Code,you must forih- qDDRESS y, SEJJER MAN � with comply with such provisions or this permit shall be deemed revoked. ' CGNTRACTOR� NO. 6K. PG, -- VALIDATION LICENSED CONTRAC70R5 DECLARATION LiC. � � I hereby affirm rhur I am licensed under provisions of Chapler 9 qDDRE55 NO. VALUATION (commencing with Sedion 700D)of Div�is on 3 of the 6usiness and LiC � � a z� 3�t 4{� Professions Coda,ond my license is in fu�l force and effcd. O�y CtA55 $ � SCZ.FI. NO.Of NO.OF CHECK #� � � �2 3 LicenseNumber Lic.Class SI7F STORIES FAMILIES ONE Contracior potc �ESCRIPTION Of WOItK NEW � S � s •CS,Oa � I am exempt from ihe li[ensing requiremenis as I am a ��� ���y� � �,�1�_ ADD � • o e'��a Q� licensed architecl or a registered prefessianal engineer AITER � FINAL octing in my professional mpacify (Section 7051, REPAIR � DATE Q�.2�]�8 Q Business and Professlons Code). U5E Of E%ISTING�BLDG. DEMOt � FINAL � Lic.nr Heg.No. Date ANPLICANT'w�� �p iEL �}� tF� BY � OWNER-BUILDER DECLARATION IPRiNt)`�� �����5.,1,h�:\] NO.��(.l"s�\�v I hereby affirm that I am exempf from the Contrpctor's License . ��r f-�� ��� fi . � - . Lqw for ihe following reason �Secfian 7031.5, Buslness ond ADDRESS �a 4. � Professions Code): �RESEN� ' � BURDING j>� � I, as owner of fhe properiy, or my employees w��th ADDRE55 �.V wages as fheir sole compensation,will do rhe work and . �'��(P� /�3 . the struciure is not intended or o4fered for sole(Sectioi� LOCAUTV j„ 7044,Business and Professions Code). � MOVING 1EL j� � I,os owner ot the property,am exclusively<oniracfing CONTBACTok NO. /1/• with litensed contractors to construtl the project(Ser- � tion 7044,Business pnd Professions Code). �DDHE55 . � CONSTRUCTION LEN�ING AGEMCY REOUiRED 70TAL SETBACK FeOM txiST. . SEI BAC:K YARD HWV pROP.I!NE WIDTH . I hereby offirm that ihere�is a mnsiru�tion lending agency for FeONi ihe performance of the work for whkh this permit is issued p.�. ISec.3097,G�.C.). - SioE � ,, P.l Lender's Name - 7 (� Lender's AddrPss P.C.Fee S ��,�� Permif Fee �'��. L} 1 certify ihat I hove read this appllcation and state that ihe issu ce Fee � - above informalion is ccrrecL I ayree ia comply with oll Couniy Imesiiganon Fee pn r. ord�inonces nnd Stote lows relaring to building construdion, Total Fee - � d ond hereby outhorize representatives of ihis County b enter �' . upon ihe obove-menfloned properry forinspecrion purposes- . - ¢ . - SEE REVERSE FOR EXPLANATORV LANGUAGE � � � Signatvre of Appl'icanl or Agent Da�e - �t n O's� y a. � U�}.L' � O � � O O �Nc� .� '� b o�+� O ��' O Cl C. cE u o � � � „ mT""'es ppm�ms°: « ao ° m � � d � d � . � y x�'a�o ; r �,e y � N�,ctr, a ='o o � � � � c '"�?YN �,�. dtJ�' h o.� �v�, mo m��.n�s `� a �^a� � °� °.V �"� � O w oihs o ay °' ••«�o�T�, a�`fl-��,�i.�"^o'a o �'�[..�-,�,�, °�' O �� ?� o y O nOn`',.�n� U� �s D �� w.� �a�� � �'�'��S � '��' x`°,� m o a�� � ��Y,v�'�+.�° r"° ° o°��:1 0�c,'�a a pV �^n;' O Q �� " O v�9� n �'Cl w C'ST � .` -O U i�" c M �`A � >-�� w � a� � t�j t""�„ s o a.� � 1 � m �,"'�,�� a 3 � "y,e o �-o a °'-�s a� � o "' � �' � c 1,� � " a �K ° � c E-� �'�ct -c� o � a 4•� ,�,�.� o� � .n �iOa 4s:�rm' 'a'�"--� f°. ov,i ` o� d � s "� '�°•o� n�o c�'„� i `� -L � �'� � a'« h`'',s,c��d'« °D c, n.° Q o o $ z,�� o"s � ° +c. c� �'�'� � V Q, rn�n-o ,�"'„ � � .�5., �m o� a o ��tJ �•�,� � o� i t c p" o o � p- �„ E _ . , �.^ �+, � Q� � �a.•� � .� o� x �, � �, � y7 m . ,'d�y s. � a,o .� � m £ C � � � � K � m ° " � � a c� " °x' p,r °' � �j ;a� r''i�.�s m���� �' v �'� a,o � ��'+��.n�� ��°' � o ° ,i+•a a� i33 E o k<''a'y v`..x d¢', ,01,R c� o m �- .:-,'r�i � n �.� ��-, 3 c d� �::^� � yia»- � o d,y, � oa �. ooa�m oa..sa �a,o 0 om g � � w o O V !. ca � ��� d .�'t ct C N 0 G A t3� Ci � Ol N � os � $ u ".�s"a �•�o��. 3 � ��ohawN °°+,-.o °_-L �ao �� � N y p Gs o��� �-°,� xQ��� � w T � a � o� � �a� � 33 d� o o m 0 }y7 � P' � a,�� `�' � � k��o �- �u; d�a,�� � ..°� y� `t'a ,`�j.�a �+V . ��a3 � �'�-�.�. :;hb c�a'��' m ` y � � o o ��.� ��^ �^ T� � � �;p�w-y,O.,,. u cy u�6�d �� t..i' .�'i'„�'�' "n �" . v ^Q N oi iV�. 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