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� : _ . ! _ . .._.. _ . . .. _ _ ._.. . ._. ._ __..._..__. WORKERS'COMPENSATION DECIARATION � ' ' � : � � � � � , - - ...... . "- 'h°�°eY°";�m'h°„ h°°e°`e`';`;°°'e°`°°°Se°"°'e" APPLICATION FOR BUILDING PERMIT iniure,or a certificate of Workeri Compensotion Insurance or a cer�Hied copy�hereof(Sec.3800 labj�C.�.)�' � � � "--'.... .. . ..... .. . . . . . -.. .. . Poltcy No✓�S�y9 �Company �Q C.2 �� COUNTY OF LOS ANGELES . BUILDING AND SAFETY - ,,:-�-- - -.. � Cerified copy is hereby fumhhed: _. / ' FOR APPIICANT TO FILL IN BUILDING 3� �� S � ADDRESS �' Ceriifiad copy le filed wBh tha caunty bullding Inspec- -�""- gUnDiNG q 3 v tlon departmenL � ADDRE55 .7 . _ ... . � �;,, ... . Date� 7.���Appllmo N� • '^v'�'�t Ctiv�•LdA+�trsw� 2iP � .. LOCALiTY ER FICATE OF EXEMFTI ROM WORKERS' � � �--- � ' �� -� ��� - NO.OF BlDGS. / - � � NEAREST. . . . _ . • ... . . � �� � � COMPENSATION INSURANCE � � . SIZE OF LOT - NOW ON lOT CROSS ST. (This section need not be complefed if fhe permif te for one �� � � TRACT �� " � - �- BtOCK _ LOT N0. ' A�M,pS�pK � PAGE PARCEL hundred dollars(5��0)or�ess.) : � � � n / _ � TEL.��/3D7-p � �ONDITIONS ON'NER�I.�.R.o'n -�NO. ( USE ZONE MA I tertify that Tn the performance of the work for whlth this � (�� �� permfl is tesued,I eholl nol employ ony pelson In ony manner qooREss 33�/ SrEanl. . . . _ . _ . . � , so os to bacame subject io tha Workers'Compemotion lowa. � �- � � � O /}� U Date . ", � ..� APPlicanl . ,: . �.�,. . Cltt.KY � 21P ` . _ . . - . ... . . . . . a NOTICE W�APPLICANT: If, afler-mokin �thie CerFlficote ef AR�HITEROR TEL.�,_ DISTRICT GROUP TYPE , FIRE OCE55EDBY O g NGINEER �� NO. �"�'� �pNST ZONE U Exemplion,'you ehouid bemme iu6�ect ro'the Workers' ����- �-^ . Compensation provtetons of lhe lobor Code,y0U IltVsf fOtth• ADDRESS � _ ,� UN � u-� with comply with such provtsions or thle pe�mlt ehail ba -.� M p� , a� deemed revoked.� � � �- �� �� �� •. , TE�•(�p STATISTICAL ClA551FICATION . . APT. CONDO, v� CONTRAGTO A%J atl.0 NO.70 a . Z UCENSED CONTRACTORS DECLARATION�� � - - --.- � - �i� � n �CtA55 NO.�DVJELL UNITS � 1 hereby offirm Ihol I am Ilcansed onder provisions of Chopter 9 ADDRE55 S 3 GJ✓ .1�d�4�f�N0.3��Y`� � ��R�P . . . (commencing with Setlion 7000)of Division 3 of the Buslneas ond . ... . . .. ���, p �� Professlone Code,ond my�icensa fe In full forca and aHecr. dTY �• GV.55 YJ �-�BK;�-- � �-� - �� - - VAUDATION _' . " ' �p/uQ ' _. C 3 p _ S4EFT' NO.OF NO.OF CHECK � . �Ucensa Number 6 �Q L���•Class � �� STORIES� � - �� FAMILIES �- ONE - . � �- . nq �9,` p VALUATION � Centratto N-� �e � O� ._� .. DESCRIMION OF WORK... . .. ; - - - � A D ❑ S ���S.� . .. . .. �. �I am mpt vnder Sec. �. .. --- f . '�. . . ALTER � B.BP.C.(or 1h15 feason . � � REPAIR ❑ . _-.. .. . - .. . - . . . . . Dote:. .. �� - USE OF �EMOL ❑ - E%ISTING BLDG. . . __. . . APFIICANi TEL � . SignaNre - --- . �. _. . _..-. . FINAL OWNER•BUIL�ERDEQARATION PRINT No. . DATE - . . � �. I hereby affirm Ihat I am exempt from the ContraUor's Ucen:e , , Law ior the folloJ+ing reoson(Section 7031.5,8usiness and ADDRESS FINAL �- � � ��PfOfeSSi0f15 COdB�:� - ���� � � �'�� � ��� - ����� ��-'� PRE ENT 0Y 41 3 9,'7 A - QBURDING 1, as owne�of the properfy, or my employees with ADDRE55 #� • ��• • 1 woges as their sole compensotion,will da the work ond� �p�IITV , Ihe s�ructura is not in�ended or offered for sale(Section � i �(��b p 7044,Bvsiness and Professions Code). - -� -��� - MOVING � - - -- - - � TEL� � - � � . -- - OCONiRACTOR NO. � �� � � u I,as owner of ihe property,am excl�sively contracfing r- with licensed mmractors to construcl ihe project(Sec- ��- pDDrtE55 � � � - �9•� ��� � � fion 7044,Businens ond Professions Coda). � - � CONSTRUCTION LENDING AGENCY sE�BACK YARD� HWY - T�TApROP uNEF WiDTH� - � � . � I hereby affirm tho�there is a consiruction lending agency for FRONT � � the performance of the work(or which this permil is issued � V.L� - - - � -- �- --- � -- (Set.3097,Civ.C.). SiDE � . . . . . . . Rl. . � lendar's Nome � ' IDMA Rei.M � _� lender's Address � � � �-- � " - P.G Fee f Permn Fee� ' 1 certify Ihat 1 hava read this opplicaiion ond stote thot the . hsuonce Fee � LDM4 P/C M . - . -. _ _ _. a6ove information is correcl.1 ogree to comply with ail Couny Invesiiqa�ion Fee � ordlnances and Siaro laws relatlng to building mnsnuttion, Totol Pee LDMA Perm.B� _ � and he�eby aorhoriza representatives o(this CouMy to eMer upon the obova-meMioned p/operry(or inspectlon purposes. Ln��'4./+�W-� � �- SFE REVERSE FOR EIf�LANATORY LANGUAGE � - SignoMe of Appliconr or Agen1 - pote. . .. . . .. r .. . . . . m;+, n= Q m l � � � � .._: _� . . � > >� � p p tn N . . �'D C � C S S `D � O � fD n� O O (la .fD - '� �� -�T -_.. ( p ' n N I 7� K � �iP �7 . O o F C7 7 n �iW o . O f: � .O ---� , - I �� o O � Q'Z x �,� - _� �� b �D O n O v.v, O. 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