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� WORKERS'COMPENSATION DEf.LARATION � � � �� � �
I hereby a�jrm Yhai I have a.cerfifimfe of consent to se�+ �� � APPLICATION FOR BUILDI NG PERMIT ���
insure,or a certificate ofi Workers'Compensation Insorqnce,
or ca ce�nfied copy thereof Sec 3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAfETY
�cyNo.��/✓C%A.���mpany.ST/7�� �/J/V� BUILDING _ _ ` ,
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 �7ay .zi1f1�%A � C �Y.
�� Certified mpy'is filed with the county building insper - BUILDiNG
tion departmeni.� ADDRE55 � pj EF' - .
Date IJ c'�� Applicont , tj(/ GTV �j (� ZIP !�„ LOCALITY .�/A /�/t.G� ���R �
CERTIFICATE OF EXEMPTION FROISc'tl ORKERS' � NO.OF eLDGS. nIEARESi ��,AID�D � A/JE
COMPENSAiION INSURANCE SIZE OF lOT NOW ON LOT � CRO55 ST. _
(This section need-not be compieted if the�permit is fo�one � � Q� � y ASSESSOR � . �
hundred doliars($lOQ)or less.) TRAC ��� BLOCK LOT Q 0._J Mqp BOOK PpGE PARCEL
p ��' USE ZONE MAP '/
I certify�ha�in the performance of the.work for which ihis OwNER sr i ' �1 NO.��l'�7_J� n J N� /�—�.7� }
permif is issued,I shall not employ ony person in any manner �� SPECIAL 7 f� �7�/ d
so�os fa become subject to ihe Workers'Compensation Laws. - - AD�RE55 � � /.J{AAi � /�'- 1��, C� CONDI7ION5 / ` t,1 `/', V
Date Applicont � .. aiv .(�/R � Z�a /�' /1J �pC
NOTICE TO�APPLtCANT: If, afrer making this�Certificate of ARCtiiiecT OR TE�. �ISTRICT .GROUP iYPE FlRE PROCESSED BY O
ENGINEER NO.
Exemption, you should become subject ta-the Workers' CON�Tr— ZONE W
Compensation prwisions of the Labor Code,you must forih- qpDRE55 �Q (� � �1 .;N
w��h mmply w�rh�s�ch pro��s�o�s or rh�s perm�i sholl be tp •.�+ re�. SinnSncn�c�nsSiFicnnoN APi. CONDO. ��Z
deemed revoked. - CONTRACTORSD/v��U NO. �
LICENSED CONTRACTORS OECLARATION � O� ���, ctn55 NO.�owetL UNiTS— .
I hereby affirm that I am licensed under provisions of Chapler 9 ADDRE55��p� Gn�E � L NO. SEWER MAP �
(commencing wifh SeUion 7000)of Division 3 of ihe Business and _ . r .L ���
Professions Code,and my license is in foll force ond effed. atv B 19 aa55 eK P� VALIDATION '
�( n 5�.FT. � NO.OF NO.OF CHKK � �
LiCense Number `������ Lic Class O SIZE � STORIES 2�� FAMILIES � ONE -
SUNSON6, VALUATION
ContraclorDEt�� �` CONS7'�P� pa�e '�ll oescRiPnoNOFwoeK � St NE`N�-O s '
ADD � ,
�1 am exempf under Sec C W�� '� �R'A � ALTER . .
� B.&P.C.for this reason -5� � j'1f�/� j C/ REPAIR ❑ S - �� 6��A .
USE OF
Date: EXiSTINGeLOG..S//I�FLE R�.SID�NCt� DEMOL ❑ . . ,
Signature � - APPLICANt � TEL . FINAL � �� � o o Z� '.
PRINT) s ��FAsar� NO. —
OWNER-BUIIDER DECLARATION . . . �- DATE .-. . ..�..- . . 1 •°']�y[�,(�.-..:
1 hereby affirm that 1 am exempt from Ihe Conlractor's License ADDRE55�I S� �C/�RE��N7 R( !"(� �� FINAL
Lpw for the following reason(Section 7031.5, Business and • g q'�5(P 4` '
"��ProfessionsCode): -'� � � PRESENT BY ��
BUIL�ING �.... u 7 L 5_� .
� I, as owner of�he properry, or my employees with AD�RE55 j n �v V J����
wages os their sole compensation,will do the work and -' ,� ���t e � � �
ihe structure is not intended or offered for sale(Section LOCALITY . - .
704a,Business and Professions Code). MOVING iEL .
� 1,as owner of the property,am exdusively controcting CONTRACT02 NO. �/!� � - .
with licensed coniractors to consiruct fhe project�Sec- qD�RE55
tion 7044,Business and Professions Code). � z E 5�,5 p. .
RE�UIRED TOTAL SET6ACK FROM. XIST. ' .
' � CONSTRUCTION LENDING AGENCY � Sei BnCK rARD Hwr PRoa.uNe wIDiH �� �-
I hereby affirm ihat there is a construciion lending agency for PRONT � � #• • e • '1 �"
the performonce of fhe work for which this permit is issued - P.L � - '
(Sec.3097,Civ.C.). SIDE � � ( � •9 9,2 5 �
P.L.
m Lender's Name • > •9 9,2 5;_'
�ry �7( IDMA Ref.!I
� Lender's Addren � � - P.c Pee$ \J. Fer..�fr Pee ��• /J`� ' �
�� ��.2F3���
i certify that I hove reod Ihis applimtion and state that the iss�an�e Fee �� s� �onna PiC k ��� �
¢ above information is correct I ogree to comply with all County �nvesrigarion Fee �
g ordinances and Stafe laws relafing ta building consiruction, Toral fee E�� LDMA Perm.#
and hereby authorize representatives of ihis County to enter �
m upon the above-mentioned properry for inspection purposes. '
Q �I��,�����.� � �� � SEE REVERSE FOR EXPLANAiORV IANGUAGE �
Si e oFAppli<anl or Agent - te ����
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