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1776A 2164A
WORKERS'COMPENSATION�ECLARATION 1 hereby affirm ihot 1 hove o certificote of consent to self APPLICATION FAR BUILDING PERAAIT 4.� insure,or o certificate of Workers'Compensation Insurance, or a certified mpy thereof Se�3900, ab.C.) ❑cY�i j�21��nY ;rr"�i� COUNTY OF LOS ANGELES BUiLDING AND SAFETY ►.� �( Certified copy is hereby furmshed. FOR APPLICANT TO FILL IN BUILDING / i ADDRESS � Cerfified topy is filed with the county building inspet- gUiLDING // /'") t tion department. ADDRE55 ( �J �s`� /� ( E Date�V�Applicant t..� I�, CITv I✓:I�: •�1� ZIP LOCALITY '�' � 1,� ; I `lS CERTIFICATE OF EXEMCTION FROM WORKERS' NO.OF BLOGS. NEAREST COMPENSATION INSURANCE SIZE OF LOi NOW ON LO7 CROSS ST. ��n� �Thi:sec�ion need not be completed if the permit is for one (� ASSESSOR hundred dollars($lOD)or lass.) TRACT � �� BLOCK LOT N0. MAP BOOK PAGE PARCEL / 7EL, USE ZONE �P ....�r �:.' � OWNER � � Y6(/ry' C ( �- NO )D I '�'� �cartify thai in Ihe performance af ihe work for which this ,` f+}��� S�CiA` I'� � .+ _ y� permit is issued,I shall nof employ any person in ony manner ADDRE55 ✓�Nd1 � � a' so os to become aubjact to the Workers'Campensarion Laws. ��,A`�U— I ONDITIONS c� CITv C3 Date Applicanf �-�� - " ZiP � ^'^TICE TO APPLICANT: If, after making�ihis Cerfificote of ARCHITECTO J � TEL. �t DISTRICT GROUP ttPE FIRE PROCESSEDBY O ENGINEER Q6 YL' ! O. �" •JCI 3np�ion, you should 6ecame subject to the Workers' / CO�16F- �ONE �� w ��sinnc nF rV�n I nhnr[ode;ynu mus�forth- ccc7.f� �%�Y �'b�i.ie °. �j�y,yr�/�. ?� �'� „� ��- withrmmplynwith such provisions or Ihis permit shall 6e TEI. deemed revoked. ^Vy`V � STATISTICAL C1A551FICATION APT. CONDO. Cn CONTRACTOR NO. _ ) � LICENSED CON?RACTORS DECLARATION ���, y ��. - `'� CLASS NO.�F-9.—�WE�L UNRS � I hereby affirm that I am licansed under provisions of Chapfer 9 ADDae55 NO. � (,d (commencing with Section 7000)of Division 3 of Ihe Business and ��� SEWER MAP Professions Code,and my license is in full force and effec�. CITV CtA55 BK � VALIOATION SQ.fT. NO.OF NO.OF CHECK License Number_��Lic.Class � SIZE STORIES FAMILIES ONE 1,, / Q VALUATION Conirp[tor ���{���K�� Date � r �✓ DESCRIPTIONOFWORK NEW ; � �� : ��_ � ; noo � , .'' l I !,b R �I am exempt under Sec. ✓ g AITER � �-t.o ., � :a�.} B.&P.C.for this reason � � '�4 REPA�R ❑ S �afe: USE OF ❑ � a�e j�j t j EXISTING BLDG. DEMOL Signoture APPLICANT (_ TEL FINAL ',a; ";:i`�:;:' OWNER-BUILDER DECLARATION PRwi� c,��r(Y�{7.Gf(.��--� NO. �ATE `��7 a;( I hereb affirm Ihat I am exem t from iha Contrac9or's License f 7 / � ��,7 6^�? Law for the following reason(Sectian 7031.5, Business and /+DDRESS �l r ;���` � l'1/ PINAL Q / ! Professions Code): � pRESENT By j�@.C<.rJv '� � � BUILDING I, as owner of ihe properly, or my employees with ADDRE55 I wages a5 ineir sole compeneaiion,wili do ilie wurk and �Q��ITY ������� � Q� — ihe struc�ure is noi intended or offered for sale(Section 7044,8usiness and Professions Code). nnovWG re�. � - ��1 F,4.A � I,as owner of the property,am eaclusively confracting CONTRACTOR NO. 'nriacan • 'I with licensed coniractors to construcl the project(Sec- qD�RESS tion 7044,B�siness and Prafassions Code). [ � e�c��� REQUIRED 70TAL SETBACK F CONSTRUCTION LENDING AGENCY SET eACK YARD HWV pROP.LINE W��TH M �y �C ti��_ i hereby affirm that there is a consiruction lending agency for FRONT ` �he performance of the work for which this permit is issued P.�. ��q�<�,,,�7 (Sec 3097,Civ.C.I. _ i SIDE Lender'sName ����131V��d'�(li%V1r_ PL �7 ' � P.C.Fee$ .;:1�/'�+�� �, LDMA Ref.N Lender's Address '�l�a� �(�l�C+S�>1� Permit Fee - , L �_ I certify thot I have read this applicatian and smte�hat the �ss�ance Fea �C�) LDMA P/C M above information is correct.I agree to comply with all County imesi�goe�on cee �A { ordinances and Stafe laws relafing fa building consiruc�ion, Toial Fee ,} Q LDMA Perm.M and hereby aut rize re es Mative of is Coonry to entei upo the ab nii ed rop t�f inspection urpos . . ,� (� � f jiy" �S / SEE REVERSE FOR EXP�ANATORY LANGUAGE ! � Signalure of Applicont or Agenf Dot � —..............._..._...........�..._........._.---—---—. -- --- -- . . 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