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0970A 0971A
� , . ,. _..- - --- _.. . . ...... ... ._. ..._._.._ .. ._— _ --.___ ---- WORKERS'COMPENSATION DECLARAT�ON . ,� . :, . -<< �- �. .- .. _._ ..�.. ..'..�-- -"-""'. , �7.. , „ ..., : . . .. _.. . . - ' ' � -_.. . � l . I hereby a�t„m Ihat I have o terlificale,of tonsent fo•self q�pp��CATION—�FOR,.BUILDING PERMIT ��: insure,or o certifitate of Workers'Compensation Ins�ronce , ( � - .�: --'--. ._. .. _ . .. , . _.____ .._ _ ,. . or a certi ie co t ereo Sec:3800,Lab.C. ' - - . ., .. . __ -.. ._� 6�W X799�3 ' ' Hat'tford Grou COUNTY OF LOS ANGELES BUILDING AND SAFETY � ; �..; PolicyNo. ompony. . . . p '_ • --.-. . -. _. ._ . � Ceriified copy ts hereby furnished �� . . FOR APPLICANT TO FILL IN i BUIIDING O � ADDRE55 � -Gertif�ed copy rs filed w th'the coumy buildmg�inspec- --" aunoiNG tion deporfinent:��� � ' ADDRESS S f � i CERTI' FICATE OF EXEMP•'�; � � .. :',; .r..� .-. . . ._. . . ._ _.. _----. .... . .,� - Dale A licanr �' Cltt � LF � LOCALIiv ' , � . . TIONFROMWORKERS .,,", __._._ . ... .... . ....--.--'-.-' -NO.�OFBlDGS�-.. - ..-.._� taEAREST._._..._. _.._,-_� __._.__.. ' .-'_.._... _ _.. ... ' - ' �-`�COMPENSATION INSURANCE�'��� , � � SIZE OF LOT r' NOw ON lDi CROSS 5T.: ' +-..- , . ., . ,... ;� _, (This setlion need not be tomple�ed if Ihe pe�mit is(oPone -'..- _ .-.... ..... . 4l . .__'___._. _. .. ._. .._. ._. ' _ ASSES$pR._ ........-� - -- ..... . I .hundred dolbrs(5100)or,�ess.),..�,•,:...,. . . iRnCr BIOCK LOT NO. �� �. AMP BOOK:. ... PAGE� 7ARCEL•. �. . . . • . . , . :. ��...... __ ._ .. . . TEI. /(�JE MAP •, . I�certily.thaf in the performance of tha work for whicFi this OH'NER'"'-� �- (�p�� _ ; � `�/.� ; ���3 _ . permit is issued,1 sholl not employ ony person in any manner . , ; y�_ --� SCECini� � �- - �� ------- -: �-�-� �a f- �' � - '- ADDRE55- � � - --- - --- -� �WO(J CONDITIONS � so as fo become su6jec�to TBe Wo�kers'Compensation Laws ,Q . . .. � . � . , , , .. �;�.... .. .... �V - . ,. .PP ., . , ',,.,. .. ;�., ._ .. CIN-__ . _.. _-.._ZIP...__ ...__ . _ _..._... ___ ___ _ _ ... _._.. _ _ __.. Do1e �. ........ 'A licanl' - � .. - :� , '�ICE TO APPIICANT: If, afte�'making ihid'Certifica�e of ARCHIiECTOR TEL. . DISTRICT GROUP�NPE._ FIRE PROCESSEDBY_. 0 I • ENGINFER Ar�m�B NO. �'p�ion;`�you-should become sobject'to�the�Workers' � "--� - CON�SH- - �ZONE- 1�'j- a.ompensation provisions of the Lobo�Code,�'yau must forth- pDDRE55 3990 W � � ' - ��---�-- -3 � w wilh comply with�such�prov'sions or-this:permit sholl be �--� ' � � � �� 'J' � " "" ��� " deemed revoked. . .:.•, , - �. . , � . TE�� STATISTICAI CUl55iFlCATION • APT. CONDO.• -� �-• �:�' `�� GONTRACTOR � NO. _ � 'L / _ LICENSED CONTRACiORS DECLARATION�..: ���+ --- - "-"��- " ' ' ' "--" -- - "--" -�� h ... ..._.'__ ..._'_. . ___._._.'_ _�.LIC._. '- -.""..� QASSNO. � DVJEIL UNITS� •2 1 hereby affirm Ihat I om litensed�nder provisions of Chapter 9 AD�RE55 NO. • SEWER MAP ' i .. . . . ... ( g on 7000)of Div swn 3 o�f the B�siness and ____. .._.___ . _ .. _. _____p�, _. � � � my I�tense's in full(orce and effect Cltt Coste Mesa CA cu55 B�� -----�-�-�-� • --- - -�-- � � - [ommentin w t Se[ti. . . . . ., SQ.FT., _ NO.OF _,_ ,_ NO OF_'_ CMECK . BK. �' ��" �i Professions Code and l�censeNumber 409Fi�O ' ��� Class g SIZE STORiES FAMIUES ONE N � ..._ . ... . ,..,, '--- . -�..---- � New--- __ � .�.._.. ..--- . VAL,DOATi7 �.F ^ VALUATION � O� \ . Comroc�or_Rramalaa falif pa�e DESCRtPTIO�O�rioR�-'PLAN 23--. �q ._5in le_Famil .Residence-_- . Aoo � S / � "JU n. «ap�� ' : ❑I am axempt onder Sec- � -- --- .._. ._-.'. ', . -. __ . . .... . p_ ,� � ' � �. NBW Constructi on A�TER � - s-. � J 2�4�'- ' B.BP.C.for this reoson REPAIR- --`..".... .. .- -""' " '- -- - - - - � ..'--.-. - - .. _"'_"..._ . _ _ Da1ei.._ ' ' USE OF DEMOL � i ' • e���i.�:� c=.> . ' - E%ISTING BLDG. � . . ..-_'�' APPIICANT TEL -- -._•_ _._..._.Signalure � - � -' -� NO. OO FINAI �y , � -_..O H Z O�8 b" � O NE -BUII D CLARATION PR�NT _.DATE--7/�/� ' � .__.._. . . `. . _..... .� .�._._ ..._�_----___. ..__.. �-1 hereby affirm that I om e:empt from the Conirocloi s license � Law for ihe following�reason(Section 7031.5,Business and ADDeE55�� � { � FINAL'�•- ��- � '� - ' � � '� �� � • ..Professions Code):.. ._...... ........_.. ..-..---'-'--�-_' - Pke ervi B � .--... __ ... . y_._, ._ . .. _. .. _�--- . . . �.. . . ... . BUILDING . .. . I, as owner of�he property, or my employees with ADDRESS `�C'n,7 � � / wages os their sole compensation,will do the work ond ��p,��TY Ihe slrutlme is no�intended or offered for sala(Setfion ' � � --7044,Business and Professions Code).---- -_.___._ .. ... MOV�NG-..'. ... .. ._._...._..._ ___ -TEL ------... . ,-._ . ... - -. . .. . . . .. � I,as owner o�the property,am ex[IusWely coMrotling CONTRACfOR � NO. . " �� ' _ r.6 • 0 • � I __- - - - _ ___ - - -----__.._.. ----- --- �_. . I��w�49.00 � � -wtth Ilcansed mntractors to�conslrucYthe projecr�(Sec--""---" aooREss - - -�� ��� � : -� ' , � tion 7044,Business and Professions Code). , , : . �.;� _ ..__ REOUIRED.._ ..._IOTAlSFiBACK FR ._. .. I . __.._.._.__.. _ ._ '_"'_ "' '_ . . °7 4�%�Ci l7� . � �� ���� �CONSTRUCTIDN LENDING AGENCY- �� ��-� � � SET BACK -YAR�- 'HWY' PROP.LINE WIDTH � • , , -; �� - � � I he�eby alfirm Ihal thera is a construc�ion lendinq aqency for fROrIT � ' � '� i ,. „ . . . 0 .2n�'n6 -tha performance oFfhe work for whith fhis permif is�issved --�-- PL-"--'- �----....'-- '- -._. ._._-_-_- -..__ . ._.. ._._._._.._ ... ... _.... �.... ... . _ :.: (Se[.3097,Civ.C.). SIDE �• i � _ ', '___ P.L. ._ ,;. i .`.1 �; . . � . ._ .; . . „� • . ._.... . . .._. . . . ..__.._. ___.-. ......... . ..... .. . . � �' .. , .. lender's Name Tnrnntn Ilomi ni nn Bank�� � � " ----"-��-�-� ���- � - � - �- - � �--�-���' G io,w�aer.x • . - - 144-Sansome-St.,-Sui te 700 - P.c.Fe�s �ZO � �� Permil Fee, ��p� - -- ! lender'sAddress r � y 17 .: -i I[erlify ihot I have read t ii appllcobon bn s ate ha t e .____. O�-(].�+J;�}_____/.r�.� '_ Isevonce Fee�--�Je'.�.--.r tDMA P/C M-..-...-..-'--..-_ ,.-._ -�_��-� �.��.. . �._: ,� above information is correct.I agree to comply with all County Inves�igoiion Fee , ..ardinances and Stafe.lows.relaling,to.building conslroction. . ...._ _.. . . ToM Fee-..��_ •�O ' �LpMA Perm.M..�.. : �. .`.. i --..._._.. . ------ ........... ._-_. ._.__.... . . . .�� :�.. and hereby authorize representatives of this County to enter . opon ihe ab e- nYoned o rty for inepecfian purposes. „p��� �� _ ---- ---.. ......_ .. . - . . _.___ . . _ _.... .. . 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