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HomeMy WebLinkAbout1396A (432) , . .. _._.:_-_----= ------- -- ------ ' WORKERS'COMPENSATION DECL4RATION - . . -� . I hereby affirm that I have a certificote of�o���,�0 5e�f � � � APPLICATiON FQR BUILDING PERNtIT � insure,or a certifica�e of Workeri Compensation Insuronce, � w o certified copy thereof(Sec 3800,lab.Cj•.. .. - . _.. .. ... ...... ... .. ...___._ _-_._-_..__.__._. ._ .-_..._.._ COUNTY OF lOS ANGELES 8 DI AND SAFETY P❑ol�ityNo. Company r`/g�el s �i, Certified.copy rs hereby furnished. FOR APPLICANT TO FILL IN Bl11LDING , `` O /�u� � . , AOORESS � U/ L7 Certified copy is tiled with ihe count bu Idin9 inspec- Buit ING f•,� 'Q� � �` fion�depnrl M.•.. ADDRE55 W 3S Wi vw ppte'. � � V AppliCaM �"� CITV N / 21P IOCAIITV �/y L . ��CERTIFIeA7E OF EXEMPTIO WORKERS' - 5¢E OF LOT O ON8 l0 CRo�ss Si.,��N A,0 �', CQ{.��M/9 � . ..COMPENSATION RANCE-. (7his sec�ion need not be completed if.the permit ia for one � �� - 3 �1� S I /+��R� �' � � � hundred dollars(S1oD�or less,� «�T `� BLOCK ior No. �,y�,p epq� P�¢ PAR�L ' TEI. U 2 E M�P / �iY I certify Ihat in the perfarmonce of the work for which this OwNER ��e� LC NO. � NO. y rmit Is fssued,I shalt nm em la on rson in an manner �,j, - SFEO,aI� - - � 0. so ns to m�e}/ bject to ihe W Y ker PCp nyp On dws. ' AWRESS - ( (�C��L�� �U��� CONDITIONS 0 Dme ` ''' 8 � . .. ; . . .. . w . � V QiY . !;'.. 1 I'y'e ...ZIP__ p� I �P�i��t � ARCHITEQ OR TEL. O NOTICE FO.�.PPLI If,-after ing this Cerfificrna o ENGINEER � DISTRICT GROUP TYPE .FIRE PROCESSEpBY Exemption, you should become ubject�to the Workers' ^ CONS/T.� ZONE �j Eompensation provisionc of the i Cade,yoV must forrh- ADDRESS (% � 4y/y LV � with comply with such-pravisions w-tbis-.permil sk�all be . . .._._. _ ., w �/ � / �}p 4� STATISTIG4L C IFlCATION APT. CONDO. Z deemad revoked. � . . - . CONTRACfOR /y NO. G �/ r � . LI(�NSED CONTRACTORS DECIARATION�--. . . .. � t rt .�� as.SS NO. �� DWELL.UNITS i here6y affir�F{pt I am Ikensed under provisiorn of Cfiapbr 9 AD�RESSQ/a� ��V�L� ,,�.33 Q (wmmencing with Section 7000)of Division 3 04 the Business ond _ � E�Q Q ��C _ �� / Rofeuiom Code,and my license is in fuli force and eifecf. cm Ctnss C"/� ��� ,�,3 VAL�ATION /� SGI.Ff. y� NO.OF Np,pF CHECK License Number�� �" ' lic Class ��� � SiZE STORIES FAMILIES ONE . �/ljV�.G6�/fl. . .. .. � VALUATlOH _ Confracbr �Date DESCRIP,IONOFW�2K � ��' s aaBD D/, �+ �l ❑ t V � �I am exempf under Sac. J� �� • ` '�r��`��R qDER Q � B.BP.C.for this leason qFpp,�R-0 i � ..-... .. . ,.� __,.-Doter._..., -- U5¢oF a . . E%IS71NG&DG. � _ Signalure ...._ ._... . ... .. . -. APPIICANi 7EL FINA� , I OWNER-BUIWER DECIARATION .. . . ..atIN7 . . . No. � � i�I :i .�!;!; �^^'^' _ DATF .�..Ahetabyof£irm�hWlcupeaac+ptfrom.lk+a. �o+:slicanse • e e •� ADORESS .` . ^a Law for fhe following redson�SecFioo 7031.5, Busineu and FINAI �PrOfBsslOnf Code): _. . .............. _, . .. ..,... . PRE _ . . . __ _ . __._.. _ . . .:'g�,_ ' -`'�+� /� ' ' � 4'-. __ / a p , Bunouv� -'`�" Q _I, us ownar of the properfy, or my employees with ADDRE55 _ _ _ _- ___---.__ .. ... . _......_._.._.._.._. .._.._.. . wages os their sole compensation,wilf do ihe woiTc and ---- � � -- �� � + � � ', , � � T �he struclure is not intended or offered 4or wle(Seaion ����TY � i � �� . �- � . . ..7044.�Business and Professians tode).--.. . _.. ... MOViNG.._. .. . . iK. - � G..H i i —n�'� . i,as owner of the property,am exdusively controcting cOrviRaCTOR NO. ��,_ � �-�., .• ..�._. . . :".:-, �. . � wifh iicensed contructors to mnstruct the project�Sec- '- - �--�-- -. ...� . ... �...... . _ . - � tion 7044,Business and Profesaions Code). AOORESS - �� - �CONSTKUCTION IENOING AGENCY�� �-�-- - � ��7ngq�K YARD� MWY TOT pTpBA`WE WIDTH I hereby affirm rhat there is a construction lending agency for iRONi ��he-parformonce of�thewpk for�which thia�permit is issued - ..-- .-p.L ...... . .. ...._ . .. ._. ._.._._ . . .. (Sec.3097,Civ.C.�. SIDE m .... . P.L. _... _ .__ . . _ __ . � Lender's Name �"- J�j � IDMA Ref.A � . .... .. .. . . ... ._... . P.0 Fea S ". .. . ._. . Permk fee..-..._c?O�'. .._ ' _ - lender'a Address �f , . � .i certify thot 1 have read this npplicatinn ond state.lhai_iha _._ _ .hsuonce Fee �L' IDMA P/C M _...- --�--' ---- -' ¢ above informoiion is correct.I ogree to comply wilh all County invasii arion Fas ��Q U � ordinpnces ond State laws.rela�ing�o building construction, � ._. . _.... ... ...' '-__.__ ....._.__... - 7ablfae'_ ' -/- '..._. LOMA Perm.M � ond hereby authwize representafives of this County to enler � u n f abpre-man one perty for inspection purposes. �.\ y.,�,$ a 1/G SEE NEVERSf FOR EXPLANATORY IANGUAGE I � �� Signnn,mvFAppficam,o.�.Age�F. _ .. ......_.p� . . .pi � o^ �r i x� L�N d �� V M -�V'� W Ol C Y•�.A\ '��" G/ N 00 � o �� y`y wh �p ';' o''v7e� oE� �, m . � �m � "'�q''•..`�y,,�. +� tt0 n !� � ��1'� D�� a.0� c,� y �U�w ��� �o� �;�'�M` ? o �,v o 7�"�•°;.� � ?' '�`w 3 y�' -� ' a) �r�- w � ti 'b}'"' �b�cick .o3.�-�",�,,;,�.M `��$� ,� � gm "� io $ ,� , i �.�� � X � .�+� a � Cl Y � O " � r��'. �k Ci`'�ti � � E o ° 4 x ,� :� a S!,���� E�a � M c���:� . v ° o o � a v�'� , _'�i'',� 4 � Qi N �.. �. " > 2 V �t", C Q� � � � tl A � ��ZS p �Zt O i . C! d . . . -'' a '� y ri �.-W.�r� b ?�a� � A'�� O�i M � O �� .7 � 0� �K'� °� . ' . � . U a ..��•�:" a` .ya- `, � � E_ o•��m m•� y,b �r"���.: m m` , � � OI �. +�1 4� 3 � fl "�l+ O ;��1 �...�,'�`'�� .X ��!'yQ. 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