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HomeMy WebLinkAbout1710A 2178A 2179A (10) ��` WORKERS'COMPENSAiION DECLARA710N . �_..�� � I here6y offirm tho�I have o certifica�e of�o�,e�,to ge�f . APPLICATI�N FOR BUILDfNG PERMiT insure,or a certifimte of Wo�kers'Compenstion Inwronce,or o ce�tificd mpy ihereof�Sec.3800,1a6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Poli[y No. Company BWIDING � Certified copy is hereby furoished. FOR APPUCANT TO FILL IN ADDRESS SQ [tJ � Gertified copy is filed with ihe county boilding inspec- BWLDING tio�department. A6DRE55 IOCAIITY Oo�e Appliconi C�TY�� `O NEAREST r Z�P �RosS s,. CERTIfICATE Of EXEMPTION FROM WpRKERS' , NO.OF B�oGS. as5es50R � COMPENSATION INSURANCE SIZE OF LOT ♦ NOw ON l0T MAP OQOK PAGE PARGEL _ (This secNon need not be tompleted if the permit is for one U ZPNE MAP hundred d011ars($100)or less.) TRACT BLOGK lOT NO. � � NO. a� � TEL oO� SPECIAL d I cerli4y thot in the performonte of ihe work for which this OWNER NO.� �� CONDITiONS O permit is issued,I sho�l nol employ ony parson in any manner r �D� �ISIRICT GROUP TYPE FIRE P SED BY V A�DRESS � so os to become subjaa lo the Workers'Compensorion I.ows. � �O �� CON57�. ZONE O .y / � Dote�Applicant —J CITY � ZIP U STATISTICALCLASSIFyyy^A710N APT. CONDO. V ARCHITECT OR Tfl. p ,y NOTICE TO APPI{CANT: If, offer making th� Certi4i te of ENGINEER NO_ 7 CLA55 NO.��WELL UNITS� pW, , � Exemp�ion, you shoutd bewme subject ro �he Workers' , M Compensatio�provisions of�he labar Code,yo�must forth- ApDkE55 5[wER r.uP Z with comply wi�h such provisions or this permit shall be iEi.�.�p p.�.� [Je9med revOked. CONTRAQOR �' No.�lS 91�7'+� BK. PG, VALIDATION � LICENSED CONTRACTORS DECLARATION - ��C. � , f hereby affirm thai l am Ilcensed under praviaions of Chopter 9 AD�RE55 NO. VALUATION � � (commencing w�th Section 700�1 of Div�sion 3 oP the Business ornl ���, �� ���' �� Professiom Code,and my license is in ful�forct and effect. CITV QA55 S�V Y w . SQ.FT. NO.OF NO.OF CHECK License Number Lic.Closs SIZE StORlES FAMIUES ONE �]`Z'1Q(� . _.. $ o.._ . CoNrocfor Dafe DESCRIPTION OF WORK NEW � 1 am eMempt from�he litensinp rqq4itp,A�enfs ns l.am.o � A� � _. �� �]�.Q a I icensed architect or o re is�ered rofessional en ineer ' Al1E& . FINAL_�` 4 P 9 __..---� ----__... _.. . ❑ - r �'=�-..^.-t -:,..-. DAiE-C�� �L . .. ac�ing in my professional cnpocity (Secrion 7051, . REPAlR Q - - " - -- � �.��� �2.� Buzinasa and Professions Code). u5E OF_ .. . �Q � -""� -- " � - � ExISTItvG BtDG. ys pEMIX � FINAL � tic.or Reg.No. Dme AG�IICANT p iE�. 8Y �"!ti1 i�s%-G;✓ �I • •6 b,4 p PRINT `�� OWNER-BUIL�ER DECtARA710N �� NO� �� 'G J�J,.$�yl i-•'-?�J �•• •b�4 0� I hereby oftirm ihat I am e.emp�from�he Contractor's License �Q� �`b(�r Law for the following reoson(Saction 703L5,Business and A�ORE55 � t7• � 0�,Q 2`$2 ProfessionSCode): . � PBES . � p`� . BUitCING C 4.� 1, a5 owner of ihe property, or my employees with AODRESS ��� ' �jd � � woges as their sole compensa�ion,will do the work and �2� �.8 f{ the shuc�ure iz nof intended or offered for sale(SeUion LOCAUTY I 7044,Bosiness and Professions Code). MOVING TEL. #����!• •'Z 3 � I,as owner of the property,am exdosively contrading CONTRACTOR NO. ' � ' �'•-•5Z6 _� wirh licensed wntraciors ta conshuct the praject(Seo , . _ ---- --- -- - � - - - - --- -Q ' tio�7044,Business and PrOFe55ions Code). --- . AQDRE55 - - - ----- --- - - "---- �----- - REqUIRED TOTAI SETBACK FROM EXIST. •'� •5 7.6 'Z / CONSTRUC110N LENDING AGENCY �r gq�g YARD HWY pROP.l�nlE WI�TH O�' , I hereby affirm Ihat Ihere is a constructwn lending ogency for FRONT �(�� 2,�8 ihe pertormonce of Ihe work for which this permit is issued N.L r . 2 ;Sec.3097.Civ.C.�. � SIDE $2� �9 A P.l. lender's Name # ' • � � � ��� $ P.C.Fee$ � Permir Fes �1 = lender's Address , ^ • �6 3,5� � I cer�ify �hoi 1 have read this applimuon and s�ate rhat ihe Cj � �,.y Issuance Fee - obove information is correct.I ogree lo mmply with oll County Inveahga��on fee._.-.-.___ ... .. + `'� �• 1 6 3 5 0 0 � ordinances and Stote laws reloting to bui!ding constroction, imol Fee ! ��J.�l1 and hereby aufhorize represen1a1ives of this County lo en1er �Q,�2••$2 upon the a6ove-mentioned p�opery for inspectian purposes. _ . � „ ���r•/'7���— ��a SEE REVERSE FOR E%PIANATONY UNGUAGF ����'�' � 't' , _ .� - � � i • n ���-'�� E L , Signo�ure ofXp�ni Agen� Oore �� _.r--r-�"'',� N . „ p+�,� s ♦ u �"s.'° `�" � .,d '�' o ���oY�' ��� �•o� V o, � o ..�s�`� u'�m..A-�-Ma u � � q� d ab O t�a ��� ? 7� ��.,,,u+.0 �y, u N'C� .aII�, �' O O p, � •Y m L ' ,�,��S i m o v�+ s,''^.�O �y y'i. �i y p-�w �,���� i m m+�..�'+ y � W -o M �.� x gV.:Q m"�m„� �-3�' 4'3.ot ex"-,�' � a�� ° c ,� p O O�S� m `1.�O � � « 4 M O .R O v ►. u �� �d o�„...,yop',,�pr' 61." a�m `��'' � °' � d� d � �.e °' �n x'� � o x°-a a o t�.�.=� m o�' � a.a v �'� 3 � E �'� � � �, ce u y � � n� ie ,� ��•��.$ >.'6 ° c,��?3 o d'�'° o ov ,�,d-`3 O ��"�,,, .�t- G� C.7�F�� � m�"' dd'� � �,3��o d : o o g x �g N Y " ,� ,°�' 6 �� `� � oE�`�c«�v ° ..-F �,�° c�'-c '� a, �o «g d '^ �{' �O Y+ i:7"' i^"„v_,.�� � Fa� r � � 'd � S °'b �� d 4��"�a�' �� G � d d z��, �r"'so.���w@ d a-� o e� g �;�� m's a� QQd � n � � "'a a a�"' ° +. }.mz+ � a ° c"a t,.� x-�s� X o«tl s c¢"� o � a U D�� .�.. w Vi M Y.w y'+�• O.¢� 'O X' ,e�'�` y� .4� O U� � d � Y O Ax3 °'�� � �"' co" �' � sEme$" � o � ovo� �-aeSo4c'� m a. d �� �6.,��d �yM � R �Sa. �u G ��+c�� �. f•'�'� Yw• w G C M^CS iy� oyn, E p O w p m.R i' c y� q G 01 � � �a.�e�*y � d.D ia'y, m N V�v� d� `�' `t� D � � y L. 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