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HomeMy WebLinkAbout1127A � (��,M�iw - Y'J3�u.,��.i�-- , WORKERS'COMPENSATION DECLARATION 4' � - - I hereby affirm�hat I have o rerfifitote of consenf to self e p�������.�_.�4R BUILDING PERMIT insure,ar o certifimte of Worken'Compenwtion Insuronce, � - �� or a cartifiad copy thereof(Set.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY P�ol�icyNo. Company BUILDING Certified copy ia hsreby furn�shed. FOR AP LICANT TO FILL IN ADORE55 � Certified copy is filed with rhe county 6uilding inapec- eU1to�N_Gq Z � � `�lTr C 6 � lion depphmant. A�DRE53v�) � NEARESi � / I� r7U Date Applicont a ZIP CRO55 ST. l/ �� CERTIFICATE OF EXEMPTION fROM WORKERS' �.�Bl�. A��R . COMPENSATION INSURANCE SIZE OP LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be comp�eied if Ihe permit is fw ona USE ZONE MAP �'2 hundred dollars($100)or lasa.) T��T BLOCK �O7 NO.� NO. � /� TEL. !I l � I `.FECIAI > WNER NO. � CONDITIONS �+� I certify that in the performaixe of ihe work for which this �� ermil is iscuad,1 aholl noi em lo an rson in a� manner DISTRICT GROUP TYff FIRE PROCESSED BY J P P Y Y Pe Y . ... . - CONSTr Z � so as to baeome au6ject to fhe Worken'Compenaafion lows. A�REu /Q �{7� � { y� � �1 /Y ( Dale ApplicaM Cm Z17 Jr'y_-.�`� �TA7ISTICAL CU+SSIFICATION APT. CONDO. 4�— NOi10E 70 APPIICANT: If, oher moking thia Cartificate of ARCHItKt OR TEL. ,1I ,r Exemption, you should become subject to the Worken' ENGINEER NO. �1q5$ryp.,�(�DWFII.11NIT5_ � Compenwtion proviaioaa oE the Lahor Gode,you fnuat fWlh- A�RE� SEWER MAP �� with comply with such provisions or this permit shal� 6e � deamed revoked. CONTRACTOR Q��t�J Np. 8R. PG, VALIDATION LICENSED CONTRACTORS DECLARATION - �C. � 1 horeby afffrm tMt I am licenaed under povisbna of Chaptar 9 ADDRE55 NO. YAWATION (mmmencirg wifh Section 7IX1D�af Division 3 of the 6uaineu and ���_ Professions Cade,and my ficen►e'ts in fi�ll fwee and effecf. CITY CW55 S�. 7 Qp � SQ.Ff. NO.OF NO.OF CHECK LicanseNum6er lit.C4aiL SIZE S70RIE5 FAMILIES ONE Con��a[tOr pote DESCRIPTION OF WORK NEW � S �I om exemp�vnder Sec. � �/�y �D � [� Al7ER ❑ DATE` �."+ I / [�y 8.8P.C.fw Ihis reason REPAiR � \ ,, ��B' E%ISTING B �� � --F� — er� ; 2� � Si nature APpUC4NT TEI. - 9 OWNER-BUILDER OECIARATION PRIM /t'd NO.�'� — �I I hereby affirm fha�1 am exempl from the Cororoctor's licente qppqESS-� � , P/'��! �`—•� -� --- - --— � �� � - -- � � Low for tbe followinq rcoson(Sedion 7031.5,Businecc and � �fessions CQde�: , wt[ _ �'� �2�a � BUIL�ING I, os ownm of the property, or my employea wilh qoox6S #• � •• �� i wage�as their wla compeneation,will do the work and ihe sirunure is not intended or offered for wle(Secfion ��°`�m 704t,Baainess ond Profass4ons Code�. MOViNG TEL. � • `61,7 5 � I,as awner of tha property,am exclusively contrading T�� N�' • • •6 1,7 5� with licensed contracforc to conatruc�the projac�(Seo- qpDRE55 � tion 7WI,Business ond Rofessions Code). O�.Z 3-8/1 REQUIRED TOTAL SETBACK FROM EXI57. CONSTRl1CT10N IENDING AGENCY SET BACK YARD HWV pgpp,�IN WIDTH � . . - - - � I here6y affirm that there is a conciruct�on lending agency for FRpM the performonce of the work for whicA thia perml�is issued P.L , tSec.3097,Civ.C.). 51DE ' . '..- - . • P.l. , Lender'a Name _ -` ' $ P.C.Fee S Permit Fee I. � S � . . . Lenders Addreu " � � I tertify that I have reod this application and state that the issua�ca Fee U• S V a6ove infwma�ion is correcf.I agrae to comply with all Counry Investigarion Fee � � ordinonces and Sto�e laws roloring ro 6uilding conskuttion, iotol fee � �� �� 1y nnd hereby authAAri:s repesentatives of this Coun�y to enMr � n 1 !� iloned prope ry for Inspaction purpoae� �� /�_ �� � SEE RFVEYSE FOR EXIIANATORY LANGUAGE �� � SiynoNre oi App onr or Apent Oms �� ' f f � � o�y t �,,.°1sw ° QN,c, � � ° � s�� N� o� ° uu o � }F�„ a '. � �.Y� ''1 'ai 60 �� C.S�� d y�, TQ�� �r,.,� o '°n C ' � . , s.s m� c,i� � 4�n�L'� ,�� ��7 0,# N ��'_ � d a`) c..n«4. '� � .� �n . N � � v .Y L d w C�"'M�a`5. T 3�y' 3.+p C"-'�" y )s S'' � y A,' ,�' ' O u a ��� d e«��`S'�a'." ° o u � w y-�� n � M . % �(-�;, � �d �, �, 6 r ,eT,,�'�' p w p.OC�.0 �. �,,,,�v �s' N � �'.+.� �.: �s ' U � c. �,W � ' ,Nl �. 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