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1178A 1179A (5)
WORKERS'COMPENSATION DECIARATION � , �here6y'affirm that�ha�c a cer�rficare af�a�,��<<o=��f APPLICATION F�JR BUILDING PERMIT LJ insure,or a-certi4icate of Workars'Compenwtion Insurance, or a certified copy�hereof(Sec.3800,La6.C.) (OUNTY Of l05 ANGELES BUILDING AND SAfETY <"� P�olicy No. CompOny BuaDING Cer�ified copy�e hereby fvrniehed. FOR APPLICANT TO FILL IN qDDRE55 2�07✓y �'QTHf�'V�Q Q� ❑ Certified copy ia filed with ihe counry 6uilding inspeo- qDDR 55 �d7 ��� 1��� a/IQ/�70R.�0 �A�j �ian depanment. oore n�u�m arv -D�A i'►1o� 3AQnP tauiErr CERTIFIG4TE OF EXEMPTION FROM WORKERS' SIZE OF lOT NO ON&LO � CROS555T. ��'7� CJRN�'J e'n COMPENSATION INSURANCf q��R �This sacfio�need noi be[omplerod i{fhe perm�f is for on0 TRAR BLOCK LO7 NO. � MAP BOOK P�F PA�� hundred dallara[E100)or lese.) �yA Z OWNERrp / ryp�_ � USFZONE '�P IOS � I cenify that in the performance of rhe work fo�which this �� � permif ia lssued,I sholl nol employ any penon in any manner u / �-+, SPECIAL � fo of to become subjed to IFie Worker�CompensaHon Lawa. '�RE� 7a�x ���� �����oO `p,/ ��ITIONS Q Ut ntr S�V/�CJiE zir 9Z7�� [r; pafe ApPlicanl A��R pp 7E1. DISTRICT GROUD TY�E fIRE 5 D BY OO. NOTICE TO APPUCANT: If, aher making�ihis Ccnificob oi ENGINEER QW NO. CONST. ZONE V E�emp�ion, you eheold beeeme subject fo fMe Worken Z �_ ,y 3 p,1� Compenwtioe provisiom of the lo6ot Gode,yoo must forth• ppp�55 '�� ` wllh comply with such provisiarro or this permif sholl be TEI. �l STAi15TICAL C1A551FICATION � ��� Z deemedrevoked. CONTRAGTOR NO. / '�� � LICENSED CONTRACfORS DECLARATION p�, .. - �u���Z�LL UNITS I hereby affirm ihat I om litensed under provisiom of CFapter 9 ADORE55 �� �yyER Mqp (commencing with Sec�ion 700D)of Division 3 oi the Busioeu and �K� . , VALIDATION Profaesiens Code,and my license is In full force o�d affacf. CJTY . �� � BK. PG. SCi.i1. NO.OF �f' NO.OF CHECK licenanNuml7er LiaClass SIZE �� STORffS v FAMIt1E5 � yAtUAT1pN Connoao� Dare oescRiaria+a womc .FN�`,T1X.C.UJs�LC.� NEW a S � ��•OD , 1.�7�7€ CAti�E,C�E �oo �I om exempt under Sec- ALTER p� : 1117.8A 8.6P.C.fw this reason �!" �P'�'�R Date: USE OF �C� DEMOI #� • • �C`� EXISTINGBLDG. f.��f� s9�o�o�e APVLIUWT TEL. � i�hAl i • •2 7,6 3 OWNER-BUIIDER DECIARATION ��M ��/ ����� N�� DATE I F�s�aby afftrm that 1 am saempt from the Contractor'a License ApppE55�7/¢Z���'� (��'��u����� �A�t,/ � � �2�6�u law far ihe following reaeon(Seetion 7031.5,Business and � f�� f Q� (1—�% Profenions Code): su�o�N� � I, ot owner of the prope�ty, or my employees wifh ApDRE55 z 1 1 7.9 A wagen aa rheir sole compsmotion,will do the work and �����, ' �he etrucfuro ia not in�ended or offered for wte(Section �• � � • • � 70J4,Business oed Professions Code). MOV�NG lEt. Z � ONTRACTOR �' 1 I • •D.A C O I,as owner of the properfy,am e.clusively cantrading witb licensed controdon to conmva the projetl(Seo- .- ' , tion 7044,Business ond Professiona Code). ADDRE55 , � ,`�� (�`.;:'�:,t . .4 3 r 0� �2EWUiRED YARD HWY TOTAlSET ACK I CONSTRUtTION IENDING�+GENCY SE7 BnGK auOP.uNE W�Diii I heraby aHirm tha�there is a conetrucfion lending ogency for pRONT I Q 1 4-8 7 Ihe performance af ihe work for which this permil ia iasued RL. (Sac.3097,Civ.C.). SIUE � �.-�� �-i":.f�t v.i. Le�de�s Nome W��� Ff/ LDMA Rei.M m �� P.G fee S Permi�Fee � � lender's Address � I cert�fy�ho�I have read this applicarion ond state that ihe �a�an�e Fae � ��P��� abova informotion is corroci.I agree to comply wifh all County In�esrpo��on Fee ord�rrontee and 5 e aw ing t uilding consirucfion, Towl Fee IDMA Perm.M a d her outh ize represenlo o tfiis County to enter � u on�h a ve- ionad pr or inspection pu�po s. 9 `Q { +� SEE REVERSE FOR E]lRANATORY LAN6UAGE � Signa�urc of Applicon�or Aqen� Daro Z o - o •� _. � ' � ro o G3 � � � `^ �, � � ,, . %'.� � a Uv T � � D. � i �n �� � � c � b �, ' �' m • . 'pa a' � �i) 1 'f' V �� J O O 3 .. O �` � - �O .� � N i �' V'p � j �7. O -c n A `" ' T J' O N � � p� 0 0 � �.- '. p' . 'Q' N 1.' N r j P � '�� �O 'yC' m ;n�, b n � ' �' • , .+ � � 'O � O ,�,* no o � � `" b a,� `. . ` . �°', � • ��� ��.' i, o q �7 ° c � ^. 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