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� WORKERS�COMPENSATIONDECLARATION '� ' ��''�.��� ". � ' � -. . • � �
.1 hereby offirm ihal I have a cer�ificate of tonsent to se�F -� - �� � -��APPLICATION FOR��BUILDING� PE�RMIT �---�� �
insure,or a certificata of Workers'Compensation Insuronce,
or a certified copy ihereof(Sec.3600,Lab.C.J .._-_ -._..- ._... . . _ .__ -- - -- - , -
. COUNTY OF LOS ANGELES BUILDING AND SAFE7Y
P❑olicyNo._61WFTX7Q�2mpany I-lar�fnrrl (;rn��n_ aui�o�rvG
Certitied copy�s hereby fumished. FOR APPLICANT TO FIILIN ApoREu oz� �� �•
r7 Certified copy'is filed wi�h the county building inspeo- � -� BURDiNG '
UU fion departme c�' � � , � AODRE55 24438 Edst T d ' � 6�,� �
Dote��; -� ,.�� � - .. . _-' _ . .__ .._.. ._.... .-...__... . ,
ApplimN GITY � Z�P LOCALITY
' CERTIFICATE OF EXEMPTION FROM WORKERS" •� - � � -�� --�----� ' �'" NO.OF BIDGS. �--� - NEAREST...
. . _.... ._ . . ...... �-.- .'- . ... ..._.. . ...
' '� COMPENSATION INSURANCE � 54E OP lOT tiOW ON lOT CRO55 ST.
(Thfs section need no�be comple�ed if the pe�mit is for one - � - ��� -�� -- � ASSESSOR _ -
hundred dollars�51D0)ar less.).. . TRAQ 42568��� ei«K �� ior Ao. ✓ MAP BOOK � VAGE. PA��
. . .- TEI. �c�{��� h1HP
1 ceriify thot in tha performonce of�he work for which this OWNER "' ""' '� "--' NO. �SO��OD� 'Y p�p � ��-3 �' • �, I
�� a
�iermil is issued,I shall not employ any person in any manner . . .� � ` � S�ECiA�.� ��-��� � � - - �
so as to become subjecf lo the Workers'Compensation Laws. �- A�DRESS�- - - �� -��� �-�-v CONDITIONS . ' �
CITY_ ZIP __ _ __ ._ .. ._ .. .. . - - - � �
Date� �Ap'pliwnt ��� ARCHITECT OR TEI. ��
DISTRICT GROUP TYPE FIRE PROCESSED BY r
ICE'TO-APPLICANT: If,�aHer moking lhis Cerfificote of ENGMEER �� CONST./ ZpLJE V I
�np�ion,�you should bemme subject �o �he Workers' - � /��j �� ��
, ... .
lompensatton provisions of Ihe Lobor Code,you must forih- ADDRESS ' �� -�� ---'" �- � �� -��-� �N
with comply wi�h�such provisions or �his permi� shall be ... tEi. 5TA7i5TICAL MSSiFICATION APT. CONDO. � Z
deemed revoked....•., . . . . coNrxnaoa • No. _ _. �-
IICENSED CONiRACTORS DECIARATION .. - - � --- ��i�.� CtA55 NO. DwELL UNrtS
I hereby otfirm thal I am Iicensed.under proviiions of Chap�er 9 ADDRE55 NO. SEwErz n�a.P � •
. (commencing wi�h Sec�ion 7000)of Division 3 of the Bus(ness and _ . ���. �
._. _ .. _ .. ,
Profession:Code,and my license is in full(orce�and ef(ect. CITY C�n55 � --�- ���BK-� ��- � "�"`� -�--�- -- VALIDATION -
' �� ' , � � � SO.FT. NO.OF NO.OF __ CHECK - ';
L�cense Numbe� '4O9b�O . ' 'lic,Class` B" size STORIE$ FAMILIES, ONE' '
� / VAWATION_Q, y'\ -C.Q i�.<3 fi--�
Bramal ea CC1�l f' • ' DESCRIPTIO F WORK '�J- N� � ��S` C�(�v
Confractor Oata . ADD S , •.•. .. .
�I am eMempl under Se[. " ALTER ,f� a L, �
. . . ❑ s
, I.^��_1..10
8.8P.C.for this�eason __ REPAIR ❑ " " --�""" � � ' � '
USE OF
Dat o�a "'��J� 1 i fi�
�'nn�j— E%IS71NG BI�G. � � - - --- -
' SignaWre . L/C.[__ -.. APaicnNr TE�. FINAL G t�<[fl"C C �
WNER-BUILDER DECLARATION PRiM NO. DATE �� � -� - � -- � -- - - - ,
.I hereby affirm that I om eaempt from the Contractor's Litense . -.
law for the followin9 reoson(Sectlon 7031.5,8usiness and ADDae55 FINAL �
Professlons Code):" '' � ' - ' ' - e ni Y � ' ' �
� ...... BUILDiNG .. . . . __ ., _. _. . � : .
I, as awner of the property, o� my employees wi�h AD�RE55 ., - . ,
� woges as iheir sole compensation,will do the work and , ' -`` ' n C
the strocture is no�intended or offered for sala(Section ����tt . �•��G' �. I{�
'- - 7044,Business and Prafessions Code). - ' MOVING - - TEL:� - . ._.. ._ . .. . . _ . ._. �
n I,as owner of the property,am exdusively convaning CONTRACfOR NO. . �l e a • o • � .
y�'� with licensed mnhactors to cansiruct ihe project(Sec- �� �
lion 704E,8usiness and Piafessions Code). AD�RE55 . I e�„ �.Q p. ,
-"� -� CONSTRUCTION LENDING AGENCY " - '- " SE�BACK�' YARD� Hwr 1O1'4pROTP uNEFR -- WIDTH o o�.��,���� `
I hereby affirm Ihat there is a tonstruc�ion lending agency for fkONT ' '
-tha performanca of Ihe wark for whicb�his permit is iasved --- -a.L. - - --- --. .. ..... ... .. . ... ..... .- -' . .. -:. . _ �; ___.�.� .. '
(Sec.3097,Civ.C.). SIDE � "' `�:'Y 5� �
� . . .. ... . --"----
_. _._ _ ._ .. _. ..... _
_.
: lender's Nama TOPOfItO �01111 11 1 0 11 B011k �prnq eef.N
s ]44 Sansome.St., Su�te 700 --- p.C.FeeE -��I./J_ P�,m;,f«- - 4�v;�.-; - - . ..
= lender's Address • ' �7 _ ` ' '�
� .-I certify that I have read Ihis app im�ion and sia�e t at Ihe - - /S,/ll. Issua�ce Fee� ���U tDMA PiC I� - ' '`� � � - -� ��
Q obova informalion is torrett.�agree fo tomply with all Coumy Investigaeion Fea r/ v i ._ . '
g ordinantes and$tote lows reloting lo bvilding tonstruUion, ,,.__ _ - Toiol Fee� v /'� LDhA4 Perm.M - . - _, , '
�
and hereby outhorize representafives of this County to enler � -
$ upon Ihe obove- ntiane proper i i ection purpos s y � _ _ , - _
-
- - -- - p_�--�-
. �
< / SEE REVERSE FOR El(iIANATORY IANGUAGE � .
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