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0909A 2795A 2796A (4)
� WORKERS'COMVENSATION DECLARATION ` S,�j � insureboraofcertifca�teof Workesr1Compensat"wnensuran e", � APPLICATION FQR BUILDING PERMIT � � or a certified wpy thereof(Sec.3800, C.)r g COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑ol�icyNo � �'� Company . R"'"""'� rj Ce�rifed copy�s hereby f�rnished. FOR APPLICANT TO FILL IN ADDRESS �`�� y �����'�''`�-'`'"�L`���' � � Certified copy is filed with the cou building inspec- BUILDING ' fion departmenl. ADDRE55 !e ! � �(y��[) ) LOCALIiY -��/'� / Q / NEAREST E. 1`�..T.2LT.1�,, �J-s+.r,++�a.�(, , �Date �I_3�(S S llpplican4-- �� arr > , :�, zir ceoss sr. � CERTIFICATE OF EXEMPTION FROM WORKERS NO.OF stoGS. n55e550e COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if fhe permit is for one �f.y USE NE, MAP { �/_ ? � hundred dallars $100 or less. TR/+�T �/C`�' �B�«K LOT NO. � �—� NO. /� '-^!'" -S� i ( � � TE�. SPECIAL � O�NNER NO. ���SL� CONDITIONS � I certify ihat in fhe performance of ihe work for which fhis OISTRICT GROUP TYPE FIRE PROCESSE�BY � � permif is issued,I shall not employ any person in any manner C, � �,�, CONST. ZONE °+� ADDRE55 L3�3 � ' I so os to become subject to ihe Workers'Compensotion Laws. ' � /� R_3 �� �' j CITY ���-+iA,.� _ vL ZIP • g Date ApPlicanl ARCHITECT OR TE� STATISTICAL CLASSIFlCATION APT. C DO. � I NOTICE TO APPLICANT: If, afier making ihis Ceriificate of ENGINEER NO. CL4S5 NO.�DWELL.UNI75_ '^� i Exemption, you shoold become subjec� �o the Workers' � Com ansation rovisions of ihe Labor Code,yoo must forlh- SEWER MAP �' P NP AD�RE55 �' ' with comply ih such provisions or this permit shall be —• i deemed revoked. ConliRaCTOR r '�� � �' r �;l NO. — C 6K. aG, VALIDATION � LICENSE�CONTRAQORSAECLARATION _ � LIC. t t I hereby affirm thot I am licensed under provisions of Chapler 9 AD�RE55 1 F ��- N��J� VALUATION � (commencing with Seclion 7000)of Divisio0 3 of�he Business and LIC. Professions Code,and my license is in full force and effect. CITY �� •��C=f�./ CLASS`�'-�� �+��L"_�" , �(]�%�i,Q�', �1 � ` 54.FT. / NO.OF � NO.OF CHECK a License NumbBr���1�S lic.CIa55 ,� SIZE (m STORIES FAMILIES � ONE � � o o m 2 3 p . s '��,- 1 v-7� � CoMtaCtor�t%'—��-�'°�'�' Date /_�� �� , � �ESCRIPTION OF WORK , �' ' NEW � � ��C-,' �� ADD �I am exempf unfJer SeC. q�7Eq FINAL y • •'�L E%� ��-cz., DATE � S�Q� r� � B.&P.C.for this reason REPAIR ❑ ��2�l—�.. 4 5 Date: USE OF DEMOL ❑ FINAL ? '7 EXISTING B�DG. �.�5 gY � :� �Y,O�-- S. � C.. .t� . .� „�� APPLICANT TEL. � a OWNER-BUILDER DECIARATION PRiNi �^ Q,. $ NO.� — I hereb atFirm that I am exem t from the Contractor's License t�� �p �y Y P I ADDRESS IO G' �Tf� ,°�ti� � {!� "�i,+.%�� , [, � law for ihe fallowing reason(Seclion 7031.5,8osiness and - :t['.�'S'vA Professions Code): �N ,,, ❑ SUILDING ri u e m�_,'�, I, as awner of fhe property, or my employees with ADDRE55 wages as Iheir sole compensation,will do the work and � �, �C��(���� the struct�re is not intended or offered for sale(Section lOCnuTv i 7044,Business and Professions Code). MOVING TEL � � �. ,,C C;� ��. j ❑ CONTRACTOR NO. ' - ` . j I,as owner of ihe properfy,am exclusively confracfing � � with licensed coniratlors to mnsiruct the project(Sec- qODRE55 ��✓� � •'��'�'`• � tion 7044,Business and Professions Code). , .i REQUIRE� TOTAL SETBAIX FROM EXIST. , L � i CONS7RUCTION LENDING AGENCY SET BACK YARD HWY pRpp,�WE WIDTH , � • � � .-=c F 9,v� I hereby affirm ihat ihere is a consiruction lending agency for FRONi ! the parformante of the work far which ihis permit is issued RL '$; �o c e e � i (Sec.3097,Civ.C.). 51DE t W/� 5 C r i� P.L. - ` m Lender's Name s e, - ' ' _J�� �) ✓/ �. i;V.::,��;^' $ P.C.Fee$ �^�'�'�C3 . Permif Fee ,E � Lender's Address � I certify that I hove read ihis application and stme ihat the 7� Issuance Fee �d' U� L y � �,��\ ¢ above informalion is correct.I agree lo tomply with all County Investigation Fee � U $ ordinances and State laws relaling to building consiruction, Toral Fee '�l�•� u 6nd here6y authori�represenfatives of ihis County to enter , � upon the ove /itioned property for inspection purposes. �-py�,� , ��� �q�,� .C�.�' � J 6 '7 �1 I ^ J� _ � � SEE REVERSE FOR EXPLANATORY LANGUAGE - I a/ I Signanre af Appllcani or Agen� Da�e ' �f f � �� � ���- ��� cD ¢ {4 I -�---" - �1 � � �� '7. �i s N Q m � { ' , � � ,�-'-�'�' r�7 ^^��� � (.�c j p '� � G �' ��,� , i 4! � '"`-""`i.�- � � f `' �'c+. � n �, 0 7 .y C1 :^ ;.z i �� 1 1 � N .,. �. �' � l4 � '.� � �.� ���p � ' � X � ; �O • n y � � y� � � �' I� i _ -�-�� �` p E ° '�R � w U' � � � �� C s � '" � ;` ���'�. �„1"�."^� "' � t : r Q � � S� S � �G"� ?a n ���j 4 -O � j t1 } �m-^;n r� a s�� m 3 � a_ n o y � � r 1 4 0-o ' c o i �. r� ;o A � ` „ ��t°° 1 � � �p cs g 1r� .c: 7 �ia @ ; � ? i �'x+' I n Q' ��'' t { o � ro c,� � � f :� 1 0 1:r� ., j � . 1 � �^., � � � , 1�i0 ��.ro In �,� .j j 7 it�, � {; � i � � � � S� i j 7' m� �'o f c � tG 2� 1 3 �..,_'�. � I ,� i, �Q�' 1� `' ^ Q� Q � lf � ! � 1, 1 -�3� o —,y _ 4 ` 1 � 'I m '� .;, Y _ �—_..-i""_.- 1':�. 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