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HomeMy WebLinkAbout0887A 2407A • �: WQRKERS'COMPENSATION DECIARATION � � ��-- � � �� � - - � � � � � � � � � � � �Fe�hby afFirm tho�I have-a ceniiimre of�o�se�„o,e�� - � - - --APPLICATION FOR BUILDING PERMIT � `"��inswe;or o certificate of Workeri Compensation Insorance, � or a cerlified copy iherebf(Set.3800,Lab.C.) � � �� � � � � ' COUNTY OF LOS ANGELES BUILDING AND SAFETY PalicyNo. Company � Cernfied copy�s hereby 1�rnished. FOR APPIICANT TO FILL IN BU�L�ING / 33 � AODRESS (O � .Certified copy is iiled wi�h the covnty bvilding inspec• � � BU4�iNG 2 q 6 �, lion depa��menL ,. AD�RE55 J ,/� � I / Dote -Applimnt . .. . . CiTVD�A/710.✓c( Lv N� lOG4uTv CERTIFlCATE OF EXEMPTION fROM WORKERS . Q} NO.OP BLDGS. _ . NEs.REST �, ��S COM7ENSATION INSURANCE . SIZE OF LOT I NOW ON LOT CRO55 ST (This scction need nof be cOmplefed il Ihe permit is for one A )�7 ASSFSSOR � hundred dollors(E100)or less.� TRAQ � J BLOCK lOT NO. / / MAP BOp( - PAGE PARCEI . . . TEI.'�f USE-ZQ NE � MAP I certify that in the performonte of the wmk for whith this - OWNER � _ �� NO. $G - �,"/ / pp. � -3 a permit is issued,I sholl noi employ ony person in ony monner ADDRESS CG T �� ONDITIONS - � C.) so as ro become subjeU to�he Workers'Compensation ws. -� � CITY / iy! � ZIP / (�,s� .. O xUate AppliCaM �-�� ARCMITEQOR TEI. NOTICE O PLICANT: If, ofrer making this Certificare of ��y DiSTaICT GROUP NPE FIRE PROCESSED Br � ENGiNEER D . Y NO. Exemplion, you should becvme sub�ect to ihe Workers' .. . _ .- . -_ . _ . 9�7� / roy�/�� ZONF W Compensation provisions oF the Lobor Code,you musf fonh- qpDRESS [ r 9 � �3 J�� N wlfh comply with svch pravisions or this permit shall be deemed revoked. ' � � --TE�� -- ' STATISTICAI CLASSIFl T�ON APT. C DO. Z CONTRACTOR �J` NO. � — � LICENSED CONTRACTORS DECLARATION ���. �'ClASS NO.--- �WFIL UNITS-- -�� - -�- -- I hereby oHirm thot 1 am licensed under p�ovisions oi Chopter 9 ' A�oRE .Q '- NO. � � ��- � (commencing with Section 70UD]of Division 3 of the 8�siness and � ���, '��R�'P Professions Code,and my license is in(oll force ond efiecL �-� CiiY � cuss � `�� _� . VAtIDAT10N . � ' . ' SQ.FT. NO.OP NO.OF CHECK . ticense Number Lic.Class .. 512E .�0� STORIES . � - FAMILIES ONE VALUATION �.7 OEKRIPT�ON OF WORK B I � N� ❑ p2� /OO Conlracfor Date --�`- A� S � �I om exempr under Sec. � � � - _ O^� � a�hR � , • � s �08&7A B,BP.C.(or thie reason REPAiR . . - . � - ' USE Of oare: exisnn�c aioc.S� /t ��},,..0 QaS I.,.u.. oEnna #• • • •2 3 AP%IGiM N� �/ // TEL.7/ Signalure � PRINT/�Ll�/l.A� /}IGe�J No. G _ - F�NAL� ^�2 . I •2 2 8 b 5 OWNER-BUIIDER DECIARATION 7 DATE.� G � I hereby affirrrl Ihat I om ezempt from the Commctor's License - - aDDRE5SC+3J In0[�-.�T 5� ���+�5'''�� ��x3 fINAL • �2 C�''6 5� low for 1he following reason(Sedion 7031.5,Business and - � � PfOIBSSiOns CodOJ: , _ ,.. .. . ,.... PRE ENT . _ _ ` ' - . - - 6Y 0�� 5-8 8 � I,os owner of the property, or my empioyees wilh AD�DRE55� < Sr /.if�tl�A Ar . . wagesasfheirsolecampensafion,willdatheworkand - L�`-ry . - r�� ��.�- �he slruc�ore is not intended or offered for sale(Section � � - � ._ . . - 70aa,Bosiness ond Professions Code�. _. . _ _. MOVwG _. _, _. ._ . . _ TEL. �---�� ' -��• �� � I,as owner of ihe properfy,am exClvsively tontracfing CONTRACTOR No. � 2 4 0,7 Fl with licensed controctorz to consrruct fha project(Seo- . _ . .._. _ . . . ._ .- . . . . z lion 7044,8usiness and Professions Code). ADDRESS . If CONSTRUCTION LENDING AGENCY _ .. .. s[�aACK YARD HWY ��Tp'p�p�INE R WIDT11 � "' �, � n• L � • s } I here6y affi�m ihm�hera is a tonsnuction�ending agency for FRONT � - • � � •2 7 9.5 0 ihe performanm of ihe work for which this permit is iesued P.L. " _ � . . - . � . (Sec.3097,Civ.C.). � SiDE • •2 7�,J�� . o.t. Lender's Name - - - '- � � . �7 p p � LDMA Ret.4 . �Q� �J-$8 l6nder's Address - . - . P.C.Fee E �`�d'4 Permit Fea . . , . 1 certify thm I hava reed rhis applimtion ond srma tho�ihe hsuance Fea 7��`-rv tDMA v/C# � above informafion is correct.I agrea to comply with all Coonry �"-- invessgoi�o�Fee Q � ordinontes and State laws reloting to b�ilding constr�ction, To�ol Fee � /.�� LDMA Perm.N and hereby authorize representatives of this County to enter - upon fhe above-menfion d roperly for inspection purposes. /�'� � ... _.. . _ - . . .. ._ . . ...__ __._ ... . �.L-/�y/��/� �� SEE REVERSE FOR El[►LANATOMY tANGUAGE � ' �S�graN.e of Applimnl or Agen� te . , - .,.. x � '_1.� �_l"_ __�_ i 0 � .. V ` � -� �. T ��" `,� 'I , , �� 0 o n:; R a o o � o � I V 1 T ' �, O. v,p F o �? � �- p ' I �T o o ° � m � � � �v ° �'-. ° "-o , -r�Q �D, '`o ,o � '" �� Z' ,I l` �� , ao = � 3 0. � y . ; - . ❑ . .. � �- v { � •. i `D`° n, �o � cu p T� Q � o� i i? � �' � a �,'';o ' ' ' � , o '.. � �z x ' ;� � ° w� p � o �� � o -- _ � � °, ;o � ' � 4 ''. 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