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HomeMy WebLinkAbout1478A 2679A . , WORKERS'COMPENSATION DECIARATION � � - � f� ��s�,e�o°a`�e,�f�o'�eo�woke=.'�omPe�so;o�'��5�;a��e` APPLICATION� FOR BUILDING PERMIT ��� .'org,cenified copy thereof(Sec.3800,Lab.C.) � � �� ' '4ay,«�a546 COUNTY OF LOS ANGELES BUtLDING AND SAFETY 'PolityNo. Company 1�RY�SI�nA[-- � `� �'� Cenii�ed copy�s hereby(um�shed. FOR APPLICANT TO FILL IN ADDRE55 '�aZ a34�{- �C.ki1JEa 1-10 R�E. �?. � Cerfilied topy ie filed with the munty building impeo BWtDiNG ^ � tiondeportmen�. /� aDDRESS �«3�"E4 �iC-1(it1G��RSf.- �(L. Date �1 � I� Applicant rAT1� V�i(�(j CITY �l�`n16Y1� pL�Q Z�P �'1��E3J LOULITY 1�rnOhD � CERTIFICATE OF EXEMPTION FROM WORKERS' •� � . NO.OF BLDGS. . NEARE57 � COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This se[tion need not be completed if the permit is(or one - TRACT 3 2�b2. BLOCK LOT dJ /�p gppK PAGE PARGFI hvndred dollars(EI00)or less.) � . c TE�' USE ZONE �P I certify that�In iha performance of tha work for whicF this �WNER - 0� � NO. -4�31 � permit is fssued,I shall nof employ ony person in any manner qDDRE55 or e� �clt�n6 1-�oabE Q. SvECIAL �i — so as�o bemme su6ject fo tha Workeri Compensation Laws. - " f CONDITIONS 0 - CITY VIatY1�1Q EJA�- ZIP 1�7 J V Do1e � Applitarrt � NOTICE TO APPUCANT: If, after moking-Ihis CertifiCafa of ARCHITECTOR ��• �ISTRICT GROUP ttPE FIRE PRpCESSEDBY O Exemplion, you should becoma subject fo Ihe Wo�ken' ENGINEER N�� /� CON T. ZONE F— Compensa�ion p.ovisions of�hr.lobor Code,you must forlh- qDDFE55 `U � �1 C�9— W with comply wdh�such provisions or.this permit sholl be ... . � - � TE� STATISTICALClA551F1[ATION APT. CONDp, � deemed revoked. � � � CONTRACTOR Pn-rio - �n NO. J'�4' Z LICENSED CONTRACiORS DECLARATION � • Q _r ���, CLA55 NO. �`1 �WELL.UNITS I hereby affirm iha�I am licensed under provisions of Chop�er 9 ADDRESS 3-ICTU'V ALL.LY �H NO. ��O (tommencing with Section 7000)of Division 3 of the Bosiness ond ' -\ ��[, I ��R��P . Prafessions Code,and my litense is in(�II forta and effect. �� " GITY W A L l�"'r CLASS L'tl� BK. �. VALIDATION � - �14 I1 /� ���� SQ.FT. NO.OF NO.OF CHECK License Number�� +u�`�' �Lic.Closs�—`"� � StZE STORiES fAM4iE5 � ONE �n DESCRIPTIONeOF WORK . N�y � VAWATION � co�noao.QA-ri�►/�i r.�C� oa,� 4 31 a� s 10 170,co , -�1 4 Z 8 A �OU FRCE�1arDi�.lGt�pCoJE ADD � �1 am exempt under Sec. �- A��R � $�� • • •2�j B.BP.C.for rh�e reoson � L��E 1��0 �CX RFPAIR ❑ f I •+�Q 1 � - - �-Da1e: � USEOF C1 , E%ISTING BLDG. K�cS����e� DEMOL ❑ • e ��I O � J`v Sigf101VrB ' APil1UNT TEl FINAL /"''� OWNER-BUILDER DECLARATION PRINT ICDCE, ��C��l AM NO. S' . DATE �Z/�I Z'� O 9.O 9—H H I hereby affirm that i am axempl f�om fha Contractor's licensa ADDRESS��� A L� � —L1J�L7Jl�i ' Low for�hc following reoson(Section 7031.5, Business and FINAL � Professions Coda): � - � � -� - � ae N BY � ❑ BUILDING ,� . I, os owner of�ha property, or my employees wi�h ADDRE55 wages ae their eole compensotion,will do the work and ' . � , the shuUure is no�in�ended or of(ered for sala(Section tOCAt�Tv - 70aa,Bos�ness and Profess�ons Code). � n40viHG ie�. . ' � 1,os owner of Ihe properfy,am exc�usively contracttng �ONTRAROR NO. ' with Ifcensed controctors ro wnstrucf�he pro�ect(Sec- � ppDRE55 ���� �� � �� - � � �lon 7044,Business and Professione Code). REQUIREO . YARD� HWY TOTAL SEiOACK �p 6 7,q q CONSTRUCTION IENDING AGENCY SET BAIX� PROV.UNE wiOTH I hereby ai{irm thal there is a constructlon Iending ageney for FRONT - the performance of the wark for whfch this parmit ie issued v.L. . ��• • • • � (Sec,3097,Civ.C.). PIDE I 9�O O �o lender's Name - - �� ` Q LD1M Ref.M • i •Cj�p Q� . . .. - P.C.Fee f { Permit Fae .JQ � � Lender's Address � a 2 6_8 8 I certify thaf I hava read this opplitoflon and atala ihal Ihe luuance Fee �O,�� LOMA P/C N obove info�motion is correct.I ogree to comply with all Co�nty Inres�igation Fee ordinances ond Slete lowe�eloting 10 building conztruction, To�al Fee � Q O IDNW Perm.N - and her by aulhorize representatives of this Counly lo enter . upon ab e• mioned prope�ty(or�nspeclion purp)o�sa[s.'� � �� /�' �?, �— �/ PK SEE REVERSE FOR EX�IANATORY LANGUAGi S�gna�ure of Appli cn�or Agen� po�e + � � � i � m„ n= m +i �n �, +� tn .-.� � �- .�,. .._. .�. ..-- --- - ...- 2 .a � > j o � a o � o Q o �o ; o na ,�A , - � ' o 0 - ,�fl � N T T .� 3 � � �r° 'r o � � � c � `O � ° � . � . - c ' ^ `� r;, �O �c � o � o D . ,� 'c _a c� = � � .� � T . � � . . . 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