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04_20_1987 - 21073 PATHFINDER RD (2)
_ __ _ _. .. . _ _ WORKERS'COA!PENSATION DECLARATION � � �� � .� ` APPLICATION FOR BUILDING PERMIT � I hereby afFirm that I I�ave a�cer�ifitote of consent ro self � insure,or o certiiicata of Workers'Compensation Insu�once, or a certified'copy thereof(Sec.3800,lab.C.) � - � - ' � � � . .. . . . COUNTY OF LOS ANGElES BUILDING AND SAFETY' PolicyNo. Company ❑ ar v FOR APPUCANT TO FILL IN n�oRess 2/D73 /�,¢ i,c.� �O• Certified co is hereb furnished.• � � Ce�lified copy is filed with ihe�county building inspao- - - BUIIDING �1 p� lion deportment. ADDRESS '4�p �.:��r�.IJ• J //�/y/OA� f}/�� Date '� APPlimnl tliVJJ�/�� /,�r/F-� ZIP . ...� LO[ALITY . . CERTIFICATE OF EXEMPTION FROM WORKERS' � ' - S¢E OF LOT tJ�G YTCC�J NOW ON LOTS O�E OSS ST. /LE� C dJ��O� P�������� � � � COMPENSATION INSURANCE � (This seGtion need not be mmpleted if tha permif Is for one TRACT - � BLOCK lOT NO. NV p B001C PAGE PARCEL hondred dollors(EI00)or les:.) . _ TEI.'J USE ZONE �P 1 certify that�in the performonc of ihe work for w ic fhis � �NER /NQ�Q. ��� NO. '�MO � f� permit is issued,I thall nol empl y an erson ner � �'/,�� p D S�ECIAL �"� — so as to hecoma subjetl to the k rs Com I ws. � � A��u�7 �����'-"'� ����� � " CONDITIONS � .S 0 Date��Applicon - . . CITY -Fie✓/�r 21P �2 �� . . . . . � � ARCHITEROR TE�• DISTRICT GROUP� TVPE FIRE P SSEDBY NOTIC TO P L� NT: If, aff m g this ertificaie of , �s/, �pNST. ��ZONE �� ' F- �Exem tion, ou should 6etama sub'ect ta�tha Workers' ENGINEER NO. O� � I� Compensalion provisiorn of fhe(obor Code,yeu must(orfh- ADDR£55 - �5�� G� ��Z' �/ � W � wlth comply.wi�h svch provisions or,�his permit shall be . . T� _ ' n. deemed revoked. - � M�' � STATISTICAL CIASSIFICATION APT. CONDO. � CON7RAG?OR .�.� O� � �aqSS NO. �2 OWEII.UNITS � Z UCENSED CONTRACTORS DECLARATION� � . LIC. I hereby affirm ihol I om licensed under provisions of Chopter 9 ADDRESS � NO. � 3 ��R�P (commencing with Setlion 7000)of Division 3 of the B�siness and IIC. � Pro(essions Code,and my liceroe is in tol�forta ond eHeti. Ciiv .�IQ�f4� C1A55 ��I BK��� VALIOATION � � �� � ' S�.FT NO.OF NO.OF CHECK � � Litense Number Lia Class SIZE � STORiES FAMILIES ONE" � , VAWATION � z .bOA — ContlaCtOl .. .,DCIe. . ' . . ... . �XRIPiION OF WORK �� I �� �f A D.--.❑ .s �D�Q��U . . . .�� �. . .2 Z. .. �I am e•empi under Sec. � j17f7/(�LGY.�M 6 8 J "��a � , 'I • •3825 B,BP.C.for thie reason gEpqig � . S _ : �Date: EXIST�ING BLDG. �FF/� DEMOt ❑ .. .._. `• • •�J�.2 Jr,c=i __ Slgnalura �-- - - � .. . a�p NMMQ /(,,t!/,�2S1� NO. y -2DpD FINAL 0 4 2 8-8 7 . OWNER•BUILDER DECLARATION p� pI q �/ - DAT � I hereby affirm that I am exempt{rom ihe CoNroctor f lftensa qD�RESS�7U'7�Z /„�T�E�L�iC✓�� /Q7IT F�NA "�6 8 6� R . Law for the foilowing reoson($ection 7031.5,Builness and ' �� � � � . Profasions Code): _ � ... _ _ ae N 6Y #• • • • • � BUIL�ING ' ' '� � � I,es ow�er of the properry, or my employees with nooaess _��q�e Gel��c� � • •5 5.5 0 wages as their sole mmpensotion,will do the wo.k and--- � �� � -��- - - �� ��� �-- �-��� �� - �- - � � ��� '� � ; � � Iho shucture is no�fntended or offered for sale(Secflon ����tt , . • • •5�5 0� 7044,Business and Professions Code). - -- h�OviNG� � - � TE�. � �i �4.2 8�_g 7 . � I,as owner of tha properfy,am axclusivaly controcting coNiRattOR td0. , � . � - wirh Iicensed controcron to conetruct the pro�act(Seo- .-.- . AD�tiE55 . .. . ....... . . - . - . ..�.�� �: . .. .. ... . . � rton 7044,Business and Professiom Code). � � �:� :'� . . --; CONSTRUCTION IENDING AGENCY -SE�gpCg -vna� HWY TOTAP OP.UNE WIDTH- ����'-�'� 1� � ��• I hereby affirm that thare is a construcHon lending agency for FRONT '� /''� �Ihe perfarmance of Ihe work for which this permit is issuad .�P.t. . . \/Q,�;q,�.� -�-Q�`SJ (Sec.3W7.Civ.C.). . SIDE �' � �, '�"- �� ,_�.T . P.l. .___' i �O�Y�C.'-n t� Y . . .. . . . . `:'.'..'1 .- lenderb Name � ��R�� N � .. - . . _ .. . _... . . -_.. P.C.Fee S�•�S . . Vermitiee �O, �rIJ�• O� C� lender':Address J I tertiiy thal I,hove reod this applimtion ond stote ihof the � Issuonce Fee . /� � IDMA P/C M . ��"�" ��"-�t' � a ve infor ' is tortett.I agree to tomply wilh oll County inves+�gm+on cee � 4-2�-� or n nc and SIo lo reloting l0 6ui�ding mnsiruction, To�ol Fee ��. IDMA Perm.X- � � �pn er by authorixe sentatives of this Couny ro enter ��� -' "� 6 i above• lo property for inspecli par ases. � � , SEE RfYERSE FOR E7(►LANATORY LANGVAGE . � Sign ure o ¢on�or gent . .. pot .. - . .. - - .. . - - .. - . .. . . . � �_. i . _ . _ _� T � ,� _ - -- � o ,o, � �, T�.. _�„ � �, o �,^ � a o o^ ; � o '� )� _� �-. .s T (�2 p 7 p 4 � W . _ ,"F ,p .n o l � 7' � � j O O - f0 (T� 7 O-� ' ] p C v^ `��'' •aD SJ Q '� I v o ' � = . ,n � a o,a D- � -"_ o n o m ; D, � p ' ^ @ x �D� _ 9 �� 'O�:� 1 � � %�� O� � � O �S ,.� . � i . � � o I w a'v i 'a 3 ' ; r. a .r QO C N O f � N m. � � .. ` . O n�: p � r,7 i� � .� � � �y� 0 p �3 � Q � � p O �.' •' C 'J � W 'D.. ry i � �; � • .� �� 7 ` ` a w �� 4 r c ,���1 -r= �1 ..� -/I � fj, ..H �!' ��J. A r � � ' _ Y �1 ��.� 31,� t�• �'�^ ~ N � 1 v �p . 1 � � � ,r �1 Z � �I � a . t. �� ., �'��� , �� �! O 0 � � Q - T' ,'�I � ', •�' ,M� �! ' '� •� II� � � � , � , . � c. 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