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, _.:. ..---. . _ .._ _.- ----- -..._._ __._ __v__. ___.... ... _�_.------ _�... . 35 ' � . WORKERS'�COMPENSATION DECLARATION '��'�.' - � ��". •i I �•"- - ,'-,-; ,: ... . . . .. ... . ..... _,_..... .. .' _ _ . •I here6y afiirm that I have a.certificate of consent to self APPLI�CATIO�N�F4R�BUILDING�PERMIT--�--�- � �insu�e,or a certificate of Workers'Compensaiion�lnsorance, or a-cerlifi d o thereof(Sec.3�0,lob.C.). ,:- . . . . . . . - . . .- . " �. . . .. -'- ..._.. .. ..___. _ ., ' 6�4fE�X1993 � ' - COUNTY OF LOS ANGELES � BUILDING AND SAFETY •, ; aoucyNo. • comPony_ Hartfnr�l frrnm � — --'--- A � �� Certified to is hereb furnished.�> • � � BURDWG � ^ PY Y �' FOR APPLICANT TO,FILL IN ADDRESS f�� S� /hQ,..►� �s �Certified�copy is filed with the munl�b ilding insp o � BUILDING �/ � . lion de�artme f.- �• ' ' ��' ADDRE55 ' , . . /�- . .: . . ._. ... . . _ . .. _ . .. .. . ... ....__..�� . Do10y��APPIiCOM CITY ZIP LOCALITY . . . � ' � ..�. - '. CERTIFICATE OF EXEMPTI N FROM WORKERS'_.� . .... ..... _ .....-.. ...-. . ._�.. �..�.NO.OF BtOGS... ......._..._.... n�aREST..._......--' '..__.-".'_"-" -'--.....—"-_"...._.. _ COMPENSATION INSURANCE`^��� S¢E OF LOT / NOW ON l0T : CROSS ST. I � �.-,�.. � � ; .�. .:...� .. . _ (This iec�ion�need nm be completed�if the permit is for'one � ��� - ---- � ������ -------� -��----� -•� ASSESSOR , ._ . ---�--- --� ^ �-•� � I .6undred dollars(E��)or less.) ,., TRACT 42568� s�«K LOT NO. MAP BOpK'" ' � ,PqGE PARCEL� , , ..� . . . . TEI. . .. . . . ...- .; . _.. . . . ._._ .. .. OWNER .. .. . . . U ONE MHP �I'certify Ihai in t6e performanca of the work for which�his Br m N�' ' ��� �� ��r 3 ' � �"-'�" ' '} permif is issoed,I sholl not employ ony person�in dny manner �. . ��� � - Sa�CiAl � -�- �-- - � -�-- -- �- - �-- -i 0. � ' � '""�- ' �'' CONOITIONS so�as lo become subject fo the Workers'Compensafion Laws. � ���� ADDRESS- �-��-�-� .21J'Y'+"'D , . .,, ...,.„ .._, v . ,.. .,.. . .. . � . . , . . . . n.� ._._ .._.. .....,.._, . .. .. . ....._... _..___._. _ Date� : ..... �APPlicanl � " . . ..�., ._ . CITY_ _.21P . - . . .,. �,a' , ��ICE TO APPLICANT: If•after mokm9 ihis�Cerlificate of ARCHI7FCTOR � , TEL. , DISTRICT__ _GROUP NPE FIRE. _ PROCESSED BY.. ��0 ( � � ENGWEER NO. - CONS Z E ~ �ption,�-yoo shovld becoma subject-to'�the Workers' --- 1 p ,,, �J .�'� .�_.�. I U py�, prowsions oa,`Ihis ermif s ADDRE55 399 W � -- -- �- �V . l�' - ' �a �ompensatlon provislons of the lebcr Code,�you must Icrth- • !�J wilh.com I with'suth ' p hall be- ._.,.._. .._. .� ...- —...._. . _.. ...N daemed revoked: -. �... .. .. � TEL. �� STATISTICAL C1A55�FICATION , APT. CONDO_•. :z LICENSED CONTRACTORS DECLARATION . � � COMRACTOB NO.HSO-�OO� '� , _.__._ _ ,____ _ _.,- � ._ �n ... '-- - - ,��, ..__. ...'_____ . ... _._._._... _. .. ..�..._LIC:. . ..._._..._.. QASSNO..-_V�: -DWELL.UNITS� . I hareby affirm ihal I am licensed under provisions of Chopter 9 ADDRESS NO. ��R�P ; (commencing with Section 7000)of Division 3 oi the 6osiness and ,_ _ _�i�. ` �� -�''� �� -' ' -- -- — - -- --' - � i Pro(essions Code,and my I cense is in folf farce ond effeU. pTY � -- -�� CLA55-.... . .._.... --- - -- - �-- - - � � VAIIDATION - -- �. ; � ..... ..� . .. . .•. � „•�' ,. . SO.Fi. NO.OF NO.OF_ NECK � � --� . BK. PG. . , , - S�zE 254 license Number �-�an�n � ' �Li[.Class -B � �- STORIES�Z���-�-FAMIUE$ -��� ��� ��ONE�- � :' � - ��G 9'L O'A ��� , .. _._ , -s l3-.f' � ; � , ,, ; . _ .. oescR�r��oNOFwoaK . ..PLAN-25 I __. NEW. � �U __ _ �� • •.�,� Conrracror_Rramalaa Calif oate � ' i �1 am exempl under Sec. � � � ADD . I •J 8� � Q _. . _ _ . . ._..--'-' -- �- � . . , . .. . - ... ALTER Q .-- , . � �8.8P.C.fortFiisrecson ..... . _� • aEraiR_❑ ._.s..__. _._...'�._.__. . __.. ;.-_..._.��•3�1,.' 0�.: .... ... ..... ..... .. .. . .D te:." ._ .__ � DEfdOI . ', . � , . � ex�sT�Nc a�o�. None � —.--_.___ D B 2 G'-8 6 --� ."..-Signature - ' � APetKaNT TEL FtNAL O NER-BUILDER DECLARATION PRIM NO. - ` . DATE-���' -•4 - �-��---� ------ �-��---���� - � . _. . - '_- . :. " _.---'-- - --- - --- '_. • I hereby affirm that I am exempt from ihe Conlr tor's Litense � ����- � � - - Law for the following reoson�(Settion 70�I.5,Business ond ADDRESS p�NpC'.�' � � ' ' • I, � . � 'Professions Code):..._.. . .... ... . ._.� ....._ __- vae N . . By ..-�-- - _.__ . . -, - r --^- - i . --.. BUILDING •-0 9 2"�-(1�- I, os owner of the property, or my employees with aDDRE55 ' ' � ` _�� "wogez as�heir sole compensation,will do rhe work�and �� � � ; �,- � � � � �i�• • ��� � the structura is not Intended or offered for sale(Section ����TY � � � - -� � ! '--- -'.-" -'-----' - �-�-7044,Business and Professions Cade). -� � MOViNG�--'- '� - � ' -TEL: �- - ---� . --- � °6�1 � ^�[]� I,as owner of�he property,am ezdusively contmcling COMRAROR NO. �'` '•� '�G;r.j �-'^T �wilh licensed mMroctors to mnsirucllhe project($ec -�-- ' - -�--' - � -- -�-- -�-- - � - � - ` ��- - -�-- � `��' - -�n"5(^,-�'��O O u 1 AD�RE55 � ; tion 7044,Bvsiness and Professions Code). ` , �<',� �.., .; REOUIRED ..fOIALSETBACKFROM "- '• �� ��• .i �' - 'CONSTRUCTION IENDING AGENCY --�- " --"----- 5E7 enCK �YARD -MWY- - pROa.uNE �wioTri � -� � - � � � ;�-�fl��C�-B 6 "� I he�eby oT(irm Iha�there is a construc�ion lendin9 agenq for FRONT . ` ' ' � � �� -.the performence of the work fo�which Ihis permil is issued... -. �-P.lr--.. . ....._ . .. _.. .__.___ _.._..---...._. ... . . . . ... _._... . ._..._.... _._..-- -._. ._... �i (Sec.3097.Civ.C.). S�DE �.�� . . ..�i � P.L. '....`' ., i. ; ..._. _. .. .. . . ...- ' ".' _" _'. :' ���aer5 r;ama Toronto Domi nion Bank " -- - �o,�,�R�f.�v � �i __..._ . 144..Sansome.St., Sui te 700__- P.c:F�,s --��I��D-- PermN Fee ---� o iS� - --.- . - Lender's Address • ' � . _ I e� �-�,_�, r. � _. _J cerlify that I have read t is opplicmion and.s�ate.that�he ..-_. /S�Y�__ IneuanceFee—. . .I�-'..`�-�' IDMA P/C�M---'�.-'�---� � ` � � ��' . .' .__._"__'_'_' _ '. '__.._._. ... ..... ... ._. ._ above informotion is correct.I agree to comply with all Counly Invesiigo�ion Fee � ' � '� ' ordinances ond Staie laws relming to bvilding constroction, ___, _. .... � � "'-'' - . _. ..... ..._...'.'""'_ Taml Fee__._. S..�--, LDMA Perm.R- ....... .. '_"..._._� ...... . .'' .. "' ond hereby authorize represe tativ s f this County ro enter �� �?,_��,_ ��.. . .--� upo e o e-m n oned p r r inspectlon p�`� � ... _ - � � --- •- - - - . _ .. . -- ---�� ---�----' ---__. - �--'._ _ . . - --._ . ._ . _. . _ . . . . . � � � SFE REVERSE FOR E%PIANATORY LANGU GE i � ��, � �� . t _... 5' n �eof pplimntwAgent . ._.... .'_�ro - . ..._.... _..'_" "_ '—"."" "'__' .... . ......_..._'___" ''_" ' "'."_. .._ .. . _'_"'� ". �'� ' �`-)" OO�� � / . ' � p^ .�i � O • . �� . ' '• � •- . . �.'' ��.- � ' .Gr ��'� lD E �� ��, .. „�' �c. a a S 1 n y , a a,. - �u+• o:p, �' �o �p ',co ,o, \ r . o .p O, O m n N m, � O .p �. 'O� � � • ` � Q n � �.Q O`. .3 p \,p �`D', �; . � :.i � 7 � �3+. O�o ��� j � t� -N� ' T ' Q �a �p� O Q� . o..Q � T . + ,:` , r,' �. 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