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HomeMy WebLinkAbout1397A , ...----..__........_.. ----..,.. _. � WORKERS'COMPENSATION DECLARATION . . , , �e�BbY affirm ihwt I hove o terlificale��o���„o=e�, qpp«CATION FOR BUILDING PERMIT � insure,or a certificate of Wwkers Compenwtion Insurance, or o ce�rified copy rhereot{Sec.3800,�a .C.)r 3 COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. __ . .Company. ' Cerfified eo is here furnished. BUiIDING � ''1 �❑ PY �' fOR APPLICANT TO FILL IN ADpRE55 S 1 QW � Certified copy is filed wi�h the county building�inspeo- WLDWG 3�3 W� ��� u tion deporfinent. ADDRESS �a,e���o,����a.r c�Tr (nI 4 �l zir ioca.irr W/�</7/N7 � CERTIfICATE OF EXEMPIION F WORKERS .� ..._.... .. . . ...HO.OF BLDGS. �+�ST. �e�Q� C(��L 1 M �' �'���^��COMPENSAT�ON INSU ANCE � • �• SIZE OF LOT NOW ON LOT CROSS 5T. (This secfion need not be�completed f ihe permit is 4or one TRACT�7� S BLOCK tAT NO. O ��R hundred dollars(S100)o�leu.) MAP BOOK � pAGE Pnit�l TEL t15�,P� E � I certify that in the performarice of the work for which this ��� G �C N�� ��(( �. l-3a permit ia issued,1 shal(not employ ohy person in any manner � . SPEC�At 6 so as to belome subject to the Wo rs' -m Mrs. aDDRE55 (��Da CO��iiOtaS u Dma�` arr �V��e zir p� _qpplimnt " ARCHITECT OR TEL � NOTICE TO�APPUCANT: If, after aking this-Cerfifitnte af �i57xiCi GROUP ttPE ; FiRE PtiOCE55Epgy Ezemption, yoo ehould betom subject to�the Worke�s" � ENGI EER NO. �pµST ZONE Compansofion provisions af the l 6or.Gode,you must forth- ADDRE55 . � (/v�G.�, ('� pW, wi4h comply wifh �ucb•provisions or this permi� shqll be y� cleemad revaked._ � � � � a �y� ��� Q STATISTICAL C1A551FICATION qpT. CONDO. 2 - �-� CONTRACTOR �,p, UCENSED CONTRACTORS DECIARATtON d v i��.r�� J'a G --aaSS w0.�DYJELL UNITS i 1 hereby affirm tFwt I om licansed under provisions oi Chapfer 9 AODRESS �O S C `/�` NO.J 7 O �tommenting with Seclion 7000)of Division 3 of ihe Business and / � `` q ��� SEWER MAP . . Aofessions Code,and my license is in full force and effect. CITV �•� M(�w�y CIqS$ �� �3� YALIDATION � 'y/ X�T SQ.hT. NO.OF MO.OF CHECK �. License Number � `�" -'Lic,Class �����- SRE � STORIES FAMILIES ONE � nQ`,�{. y,��/� y///��,�/ �/ VALUATIQN Vf7N'+�U!�'�J �Dafe�� DESCRIPTION OF WORK ....... NEW f V V Q� COnV4CfOr ADD � � �I am exempr under Sec. - `� - �• t� AtTER � B.B,P.C,for�his reason W �pA�R � S - � - - � �ate: � USf OF ❑ EX{STING BLDG. �FMa �SignWure - ' AVPLICANt-. .. iEL. ..._HNAI :-i 5 Q 'F. OWNER-BUILDER DECIARATION PR�M NO. �E-- �y I hereby affiww�hW lom esempt from the Contractor'a License -.... _......� . '"'t.-.... _. . ---- - y o . • n �j - law for the following reason(Sec�ion 7031.5,Business and ADDRESS FINAI �� - Professions Coder..... .. _ . .---.._...__.._._ . � . .$ � w;� '-„� _ ... _ y_ ...., . . _ ., �.,� ❑ 6UILDING �, as owner of the property, or my employees wilh MORE55 �_ �,.,r� wages as their sole compensorion,wiil do the work and � • � -. the sHucture is not intended or offarad for wle(Sedion ����TM • � � 70d4,Business and Rofessions Code). � AhOY1NG� �� � 7E1. ��.� .� _ �� � I,as ownet of ihe property,om eztlusively coMmcting COMRACTOR Np. � ;� - , -wRh licensed�ororoctors to constroct the project(Seo- '" - qDDee55 tion 7044,Business ond Professions Code). ' ---��CONSTRL1CT10N LENQING AGENCY . . - SRE�T BACK � VARD 'MWY'. .7�'L�.LINE WIDTH ... . I here6y affirm that thare is a consvuction lending agencV for FRONT �� the parforrtwMe-o€-ihe wwk-#or-which thispermNyrissned ... P:L. (Sec-3097,Civ.C.)• SI�E . P.L Lender's Name ry q �� m _. . . .. .__. _ ______ _ ___.- . P.0 Pee S Permil Fee ao�5� . LDMA Ref.9 - Lender'a Address �v � � 1 certify that Lhave.read this applimtian md state.thot�he ...... ...._.. ._. ... ..... � w�a�.ce cee �� IUMA viC S . . ¢ above information is cwrect.I agree w mmply with all County invecrigation Fee " g ordinances and Stote lows relating to building wnstruction, /�3�f , u and hereby authwize representatives of this Counry to enter iowl Fee iD/uw verm.M m u th abo -menti ed properry for inspaction purposes. � DN Y� -Qj SEE REVFRSE FOY EXPLANATORY LANGUAGE � Signoluro of AppFicanf or AgeM- - - Dute --- - ' -- . rp i � b 1 N (U T. .L� Cl Cl N1 .N C.(1 01 N • �� �"4 �'r. F yb 1!.p�O �� . C i �� � ���w � O 01 ~� V� � ' . ,. , O� ! � y .`! `O.- �.r. Oi � �•�.O 3 p� � `'y,." . C . tn .3 H .. ' �� w;d °�.' ���e�m o� y o y'.7��� s h v o:� ° d � y`�.� u . 3 O �. �. ,n-�"' ti �i+ 0. �.�—x Zv°�n cyd�yoR4�^ d � —°ndm.~°. ��c,�y � > aUi°. `��7 ro .. 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