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1249A
.. . _ . . . .. WOPCFRS'COMPENSATION DECLARATION • - � �� ���� � • � - � ' I herc`�y oilirm ��o�I hove o�e,,,�,�o�e of�o�5e�,�o=e�� �� � ��-�- � �� APPLICATIO�N FOR��BUILDING PERMIT � :� � insv�e,or a certificote of Workers'Compensarion Insurance, or o cerrfied copy ihereo�(Sec.3800,lob.C.) . - �QUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Company BWIDING 11 1 O � OD� � Cerliiied copy�:hereby lurnished. FOR APPLICANT TO FILL IN ADORE55 `"S' � Cerlified[opy is tiled with Ihe tovMy building inspec- BURDiNG r p � � . tion depanment. , ADDRE55 � �� -�� `�1�� r�p'�D ��• Da�e Applicont � GTv D!/�,MnNI� �7� Zlr �JJ IOCAUTY Q� CERTIFICAiE OF EXEMPTION FROM WORKERS'. �. . � {'O�X�� �NpW ON 10T5 / � C O55$L � � � COMPENSATION INSURANCE � . 512E OF LOT (This sr.ctian need not be tomple�ed if the permi�is(or one ASSESSOR hund�ed dollan(5100)or less.) TRA�T �� btOCK � l0T N0. MAV BOqC PAGE PARCEL L iEl(7�r� --� l ,�, us�zor,e � a I terti(y Ihol in Ihe performante oi the work for which this OWNER //A,}))�j �• rTD.�� _ NO. L'�"1/C�7 pq, permit is issued,I shall not employ ony person in any manner ,f.. /��n ;1n SPECIAI _ U so as to become wbject to tbe Workers Compensofion laws. � - ADDRE55 �� J•�ro�� �-GJ�l;C lJC CONDIilONS ��o�i3 n i��a„��t7/�rnF.1_ l., 1�2To�1_ cirv L7/7/I+a,vD �^,�' zir �/7G� o Date PP r-- ARCNrtECT OR TE�� �ISTRICT GROVP iYPE fIRE SSED BY NOTICE O FPLICANT: If, aNer moking�his Ce.tificate of ENGiNEER �� ,� CONS{.�' �E W E.emption, you should become subjet� to �he Wmke�s' � \�jV _ ( Q; Compensalion p�ovisions of�he Lobo�Code,yo�m�st fo�th- ADDRE55 �� � i1h comply w Ih such p�o��sions or this permil Sho�l 6a .. iEL � � � STATISTICAI C1A551FICATION APT. CON00. Z deemed revoked. � - C�W U��(1— CONTRACTOR NO. LICENSED CONTRACTOR$�ECIARATION �IC. ,, . MSS NO. �WELL.UNITS - I he�eby offirm�ho�I om licensed under provisions oi Chop�er 9 ADDRESS� NO. ��R�P (tommenting with Section 7000)of Division 3 of the Business and UC. . Pro(essions Code,aod my license is in full farce ond eHecL �� - CI�Y�' -� � �� �-" � � CLASS . BK �. - VAUDA110N � � SQ.FT.� NO.OF NO.OF CMECK ' li[eMeNumber � IiC,Closs � SIZE � STDRIES -� � FAMILIfS � - ONE , VALUATION Conlmtb� � Oale OESGRIPTION OF WORK f1A JT DN UP N� ❑ = OO� S. . _ .� Fl�.l�I�.✓T-E� /N L1I�IJJL Ri�dM ADD � �I am e�empt under Sec. � .. _ /�n AITER� � � 8.8P.C,for this ieoson � �Z�k /�'b�� �w0 �1 REPAIR � s . . � �ole: USE OF- - ;� EXISTING BLQG. S�NG�rh��L� '/(��uA'bEMOI ❑ 5;gna�ure AC7lPRl TT a!�n!!�/_ �, f���TU�ni�.7/�dl./-Jlli FIHAI✓ '1 > ,/1 . OWNER-BUILDERDECLARATION t d onre.�,'✓=> �7 I hereby a(firM that I am ezempt from ihe Conimcior's license qDDRE55 uIO ��r��'� �-��!� �7/� I)1rt�"�Pu7+ ti��Q FINAI Low for the fo��owing reoson($ection 7031.5,Business and 6 �Vrofessions Code): . . _ . . vRe N .. . . ' ... . . . y ' , . ' . � BUILDING + ' I, as owner of tha property, or my employees with nDDaE55 � "` ' I � wages oz their sole compensa�io�,will do�he wor4 and , the svocture is not intended or offered for soie(Setlion ��"��T" . ,. �� 2 p,q p 70<4,Business ond Professions Code). . . . MOVING . . ..TE�� � � -- ' - �� � � � \ � I,os owne�of fhe propeHy,am exclusively coMrotling CONtRAQOR �. .. ... ... NO. : # • . • � •: � with licensed coM/atlor]to construct Ihe prOjetl(Sec- . A�ORESS" �ion 70d4,Business ond Pro�essions Code). - � . 1 �� I • •3 0 5 0 REQUIRED 107AL SETBACK - � , ' .CONSTRl1CTION LENDING AGENCY.. . . 5ei e/CK YARD HWV p�p ��NE yyipTq . � � � � f hereby oifirm ihal there is a consrtucfion lending ogency So� paONT • � •3�'j�� the performonce of Ihe work for whith this permit is issued V.L . . � (Sea 3097.Civ.C.�. - SiDE O A 3 O—H S P.L lender's Name - . O O IDMA Rei.M � � � ' P.0 Fee S iermi�Fee . ' � ' Lender's Address 1 certiFy thal I have read this applicallon and stafe Ihat the Iseuonce Fee I O LDMA 7/G N � � above informotion is torrecl.I agree la mmply with all County � inves�+gaf�on fce � ordinonces and Stote laws relating to building construction, Toiol Fee toMa ee.m.N an rcby au�h iza represen�atives af this County to enter u�n+ e o6ove-r�en ion�pr perty(or inspeciion purposes. . / ^��/} ,i ° L 6 �D G"� SEE REVERSE iOR E)f�UNATORY LAHGUAGE Signa��re of Applicont or Agent e \ � �-10 °. � - , � � _ - :�_ , . .. . � -�i� �� � . 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