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1419A
. 1' \YORKERS'CO:"•PENSATION DECLARATION �j I I hereby a���,m ihcr I hovr,a«.,;�;�a,�of consent Ip se�i APPLICATION FOR BUILDING PERMIT insure,or o certllim�e oi Workeri Compenso�ion Insurance, �� or a ceriilied copy thereof(Sec.3800,Lab.C.) � COUNTY OF LOS ANGELES 9UILDING AND SAFETY P�ol�icyNo. Compony Cerr�fied copy is hereby tum�shed. FOR APPUCANT TO F LL IN Ap��DI_N�G� �f / J y � � Cariified cepy is{iled wiih ihe touniy building inspec• BUitD:NGr`� �' , / tion depa�lment. ACDRESS�—.(�� �� �L� �7 _ l _ � Q' - t Da�e ApplicaN CITY l Zio LOCALISY Yn�JGr'1 � _ CERTIFlCATE OF E%EM,PTION FROM YlORKERS' SiZE OF lqi , � NOW OY`IOTs CRO$$SST �7 � ��� COMPENSATION INSURANCE (This settion need nat br.comple�ed if thn permit is for ane 7RACT � BLOCK �LOT NO. MqPSBOp( C\ PAGE v PARCEL hundred dollors(5100)or less.) fEt. US OV' MAV • 1 cerlify ihot in�he pe.rformance of ihe work ior whith lhis CWN�R �O. v% NO. '���� permi�is iswed,1 shlfl no�em�oy9rLy pe�sopircoAy monner �� _ L� i.,�/j J SPECint � � ADDRES� CA� I CCNDIilONS' so as ro be omr.Sub'ec to�he W6 e�s Com ensati/on lows. � O Dnie � Appl�l�- �' "`"N. '�[1�y pTY C NOTI T PL CANT: 1(, ller 4angG�s Cerfi(ito���of ARCHITECi OR TE�� DISiRICi GROUP SYPE FIRE RQCESSEU BY O E�empion, �jou should become subjecr fo the Worknrs' FNrINEFa N�� �J CONST./ ZONE n � Compe�smian provisione af the Labor Code,you mus�fonh- ADDRE55 " � wi�h co^!^!y •�ti -�:h previsiors or Ihis permit sV�o(I bc � �'� deeme.d�evo4ed. / 1 1EL. �'- STAT15TI(Al C1A551FI�AT10Y APT. 040p. [n CONTRACTOR�' �O Z IICENSED CONTRACTORS DECIARATION � ,�f�/`/ / � �i�. ,/1`� MSS NO. D'1��11.UNiTS ^ I here6y affirm thot I am licensed under provisians al Chopler 9 AD�RF55/_///.7 _ � N . �`/,� (commrncing wi�h SeUion 7000)of Drvis�on 3 oS ihr.Business and �i� SEvfER tMr Pro�essions Code,ond my licr.nsr is in full force ond rffect. Citv :�7< �/�7 ���� � CtASS ���� BK. �. VAIIDATION 9 f 50. h0.OF NO.OF CNEC License Number ( � �Lic.Clas '�� SiZ . STCR�ES FAM!L 5 ONE Y�ATION � / DE .'PL'CN OF V/CRK i(� hEy� ❑ Controt�oJ �'- Doie '� U ;� S O 1 �A�°=�' � I am exemp��nder Src. � ALTFR B.BP.C.tor�his reason , / � � REPnie ❑ � :^'1 4��n,'+ U5.OF / � Daie: E%iSTI^:G BIDG� ( CEMO� � $i• • • • •� � SignoNre nPPII�ANT / �H✓�� �u�'��?i iEt.�'�x 3�^ -7 FINAL OVINER�OUILDER DECLARATION ICRINT � n0, 3 S LOATE 2��� � ' '4�a C'O 1 hereby af(irm ihal I am exempt from ihe Confrat�or's Licensa lnw for ihe(ollowing reoson(S^<fion 7031.5,Bus�ness and ADDa�SS ��- �i'y� FINAL �'� • • •�i ;.���;� Pro�esiions Code): �2 h SY L � 1, as owne�of the preperly, or my employees wilh ADCRE55 G C G 7—t"r" wa9es os th�ir sole tompensaiion,will do Ihe work and , the structure is no�intended c�ofiernd ior zale(Section lOGnuTV 70d4,Businees and P�otessions Code). 1.'OviNG TEI. � I,as owner of the propeny,om exclueively conrracling CCNTRACTO4 h0. wiih licensed toMractors lo construct fhe project�Sec- ADDe�SS t�on 704a,Business and Profr.ss�ons Cede). CONSTRUCTION IENDING AGENGY sEi Bnc YARD ��wv ����pRCP.L h�� V,� wiorti I hereby offirm that there is o consuuciion lending ogency for f uCr+l �ho pertormance of the work for which�his permi�is issued v�. ($ec.�097,Civ.C.J. SiDE P.l. Lr.nder'S NomC L041A Ref.K P.C.Fee S P��mir Fee ��•S� ' lendei s Address I cenify ihai I hore rovd this appllm�ion and sta�e�hae�he heuante Frn �� .�v tD1M P/C M abovr,informolion is torrecl.I agree 10 comply with nll Counly Invns+�ga��on Fee ordinances and Stale lows relo�ing to huilding consiruc�ion, Tobl Fee �• O � LDMA Pr,rm.N and hcrcby auihor�e iepresentmivr.s of this Counry to enter upon ebove-��' nffftio///ned propc�ty for fnspeclion pur�o es. ����a� 7 �� SEE REVFRSE FOR F%PLANATORY IANGUAGE S�e Appl�co��o�Agen� Wi�e \ � �/'\ `\c 9 ' ��:, � � \\\ , - � . �-� �' - ; ;, `o /� i � : ✓ c� - �'• �\ � o �; G �� C; t . \c r r�' ',s • C 0 \ ,C % O� L1, '�: C: < ' \ r / f�f � i� /�',��jC ' '- \ •iw - \��\\ r \ �. , A� J n v r�V\', ., ,2 c" ,= . ` • \ ,` �J,i x\ O /�('� '-•, � c '• o�� T� !� ,.- \ -� " \, ��/ � \�Q�l T-c �'` ^ O .� �n �\ q `n '�> . -. � \ '�` ` C ' \ 7� \ �,� c ''l ��-., _, !' A v' ,\` < '= '/ .c / \ . 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