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10_25_1984 - 21015 PATHFINDER RD
. . -.,:, . . . .,,, '.. .-------....---------- -- -...___ . . _...--------- -....__._...._:1............ . . _ _. . .._ �'S'COMPENSATION DECLARATION , '� ' ' � � ! —� �,��,.. ,•. ..,...._.� � � �.::., ',�•', ..., . � � , , . � --._...-�- - ' - - -_. �.o�e a ce�tificate of.consenf ro=e�� � -APPLICATION _FOR..BUILDING PERMIT � "brkers'Compensation Insurance,' . �....'"."______. �(Set:3B0jQ.�{ab.C.): :�"����,�'� • •; , •, _COUNTY OF LOS ANGELES•� ! BUILDING AND SAFETY ^ ,-��fJy �� � .�mpanyl!/�41�►`� -• - � � � -. ... .. BUILDING� � � .,•ts hereby fomished '. - � � FOR APPUCANT TO FIIL IN � ' ADORESS 7 .P�7/ ...ed'copy is iiled�with�IFie counly building inspe�� BUIIDiNG��� � 1 , . � ��ion-departmeM: •.'i �„ � . . . . �• �� , ADDRE55 � � . .. .. . ��.� .._ , ,.. _. _ . . �} 1 �1 aie � .. ."-qpplimAf '� � I CITY ZIP LOfAtITY �``� . , .. . �. ,.... ., . � , . ; '�• CERTIFICATEOFEXEN�PTfONFROMWORKERS' � �1 ' - '- ' '�-- - " �"--"N FBLDGS- - -� - - .•---._.._ _ ._....__ ._ . I O.O NFP.REST nA � '�- � � �•�COMPENSATION INSURANCE -'� � � t SIZE OF LOT rL NOW Onl lOi� O CRO55 ST.,. '(.���� � ,' � ��. I ' " .. ASSESSOR...y.. '--'•._ - (Thls secfion�need nof be cdrtipleted if the permit is for onA -�-� - TRACT BLOCK� lOT NO. 2 N,qp gppK " ' VAGE� PARCEI hundred dollars(S700)ar,less,) a��,- . , ,. . I � L-1 � Y. P ' ._,... OWNER Po ''.�NO. IQ`I I r U^ E MAP •. _' � Q" Pcertif that in the erforma�e�f�rYPwork for which.rhi. . , /1 ..,. , „ NO. � . . . ,. ��..y/�� . � ���._ SPECIAL'' '' � " ' ___' _ ' ',y � ermit is issued.I shall not em lo an �erson in any m!y�^]5 .. .. - ADO � �T -I�M`-1 R �..... ..-" - �-�- � sb as to become�sub'eci to the Workers'Compensmion Laws� � ..„�-, .. � .... .....:. . .. .. ... . . . . ' L��1 _- - .'-. . . ... . . . . .... . . . . _ " ' RE55 � �� CONDITIONS v �afe �, ..'. ' APPlicdnt.y „ .�...,..., �.-.. ' . .- CIiY-._� -� � -.._. (.ZIP.'..-1-1.� .. ..._ . NOT�CE TO APPUCANT:`If,�affer makin�'this Certificole o�� ARCHiTECT �p��1 TE� � D�Sii<ICT_ .GROUP ttPE. �_... . _FIRE PR EDBY- - , .. . 9 ENGMEER �. .I�IC. _ ..... !'�-ri. NO�I��7�'1�1 CONST.� ZON� I E■emption, you should 6'ecome subjec('fd'the�Workers' '- � , �p�/1� � /AI/ . Compensation pr6vlslons of ihe Labor Code;'yoU must farth• - ADDRE55 � �L�� V�Y�,V� �'i��- � - ��` � with camply�with'zuch provisions or this�permit sholl be -�---- • TEL. , STATISYICAL CIASSiFI TION . APT. CONDO. deemedrevoked. �' � ,.� ,' ��.� �.. ,�•;•��,:.� �`. ' y �ONTRACTOR NO. . . � �..._._ . .._ . .. . .. LICENSEDCONTRACTORSDECIARATION'�.� -.; � ...--- ----'--._. _._ ...__-.. ...__ ..._. --tIC:.. .- . - QA55N0. - DWFIL.UNITS' � �' _ I hereby affirm that I am licensed under provisions of Chapter 4 noDRE55 ' NO. • (commencing with Section 7000)of Division 9 of ihe Business and __._..- ._._ _ _ ._........_i��. ..._ _ � �P ' � � ' Professions Coda,and my Iicense is in full iorce and effect. CrtY � ' CL455 � " �� • '�--� VALIDATION � ..,,. .. , �] . . , i'_ ._. Sp.FT. .. n NO,OF.� _ 'NO.OF__ _'__ ' CHECK_; ' . _ __ _ SEVJE . .�BK. . I�� . � • liC.Closs � SIZE L�STORIES L'�"-'FAMILIES ONE . .. .. �� ='�.�.�',� 'i License Number � ' �� � Contractor Dar' � _.VALUATION. --.'_.--_.' ---.. .-—- ....... . - ---. " �'Fo��tC'bi257�.... .... . . ... . .... .. _ _ New._ i,i�� �> . . . .��i . . �,� DESCRIPf10N OF WORK �' �L � a � I e AD� � T . "_" .'.. �I am eaempl onder Sea .. - . . `p ALTER � ,' � �.� �:� - -- ' I : ' . ' _'_.. . . ... . . � �� : � ., B.SP.C.for�his�eason ' � � . ❑ S' G�j.�� �--' -"--� �--- �"�,i� ti- - ; ."'-. . . -.. REDAIR - . ___-__' _'____ _ __'._.___'_ _ _'.__., . ; � ( : . � . :. • - Date: - USE OF A I DEMOL Q ) ,� . � ' ` . � � � -.,, ' . E%ISTING BLDG. IU - � - , � _ - � _ .:, ,.... . __' - �j� I � V I . - _ .. "':_r,: :.. I .....Signature . . � .. ' -" _ '""' '_' APRICANT �y NO.GlO�� 7 � FINAL ��/ �Ir � �J . �.... � N OWNER-BUILDER DECLARATION � PR�M ' -- DA�E----- � t �-----� ' i � i hereby affirm�ho�1 am exempt from the Contrat�or's license, qDDRe55 ����� ����� . �� � '�'' '' ' '' � � taw for ihe follawing'reason'jSectfon 7031.5,Business ond � � HNAL ' J� '� � _ '.' ' _.'_.y�_ ._'. __ . _. ' �� '"ProfessionsCode):-. '- . .. "`.'. . _.'-'"- -•"'-�' � " ' 6y f� . --- BUILDING � � _� I, as owner of the property, or_my employees wNh' pDDRE55 �� .� . _ _ . _ _. .. _ .. . - ___._. woges as their sole compensation will do the work and ���TM . ��'(� . ( � the structura is not intended or offered for sole(Section. ' • � � ' � - � -7044,Bustness ond Professions Code). �' -- ..-. . . nnpviNG--'-�--'--- ....._.._... ... - -�-TEC -------- -... . -%, - 1 ; . .-.. . ;._ . ._. . . ..� S , � CONTRAROR NO. . t��L i B/�l� , � �':._ : ': I,os owner of Iha property,am exclusively conhacling' ' • " � � � . � �� ` ..� -wirh licensed conrracrors ro-cons�ruct�he ro�e[t Sec.�----' AREQUSRED- -YARO HWY TOTALSE78ACK{R M xl .� .-..r� -.?G�„"_Vi��i"�(/C-%.�•�'.Z/!T.- 1- .i'``.�,`"I �� P I ( �C/ I tion 7044,Business and Professions Code). , � �"-"'���- �CONSTRUCTION IENDING AGENCY� - ser eaa PROP.IINE wioiH �� �� I ��; ���� � , 1 hereby affirm that there is a conshuction lending agency for� peONT � �� q 9�Y� " �` �� �' � � -the performance of fhe wark for whith this permif is issoed . . -. .-P.L.-"" ' "".' .".....' '___._.._ .-_ '____'_ ___.' . '_- '�------�'-`-_---------_--'"- - - i:-j !� I (Sec.3097,Civ.C.). SIDE , " ' . . _..___ ____. _ .. ._. .'."'_'__.. ..... _ '__ __.._.. ._P.L'_.__. .__ _ '.'___._-'_.__ _...'. __ ._'_._. .__�._ .e.... . .-. .._._ __�.__. _.__._ _'_.___._._ ....._._ . lender's Name /� � , .'_.' _'-_ _. .' ._ . .'__. . ' . '. _ � _ .__ P.C:Fee E-� i� •" Perml�Fee--. �3 �J(/ LDMA Ref.M '"._ _ . '. Lender's Address ' �j� n, � '�� ''�• �' �� � -I certify Ihat I hava read lhis applicolion and stale.ihat iha ...-__. _ f/ - , /�� hsuanceiea �/� 1 � ��� � �� � ,� . -7- -'/D �CJ. _.'.'. D�v_- IDMA�P/CM��✓-OIb��'. ,-___ ' _ _ _.__ __ . _ ...__.. . obove informa�ion is correct.1 agree t ly wiih oll County� imev�garion Fee ����1y�� /� � � _+ . ordinonces ond_51a1e.laws reloti f ilding consiroclion, ,. . . __._..... . ...... .._._.____. Torol Pee � v � tDMa Perm.M ' r� - ond h by au�ho' represe ti of�his Coumy to eMer � —' up obov enti n o ' peclion pu�poses. , ' . _ .- - - . . . ._.—'�- -----' ---'---_...._ ._ ' i _.. .. _ . __._._. . i. �//�/�--/f7{/-����J - —---- ---. ._ ._.... ..---'-- � �Q y SEE REVERSE FOR EXPIANATORY LANGUAGE � � ��/� ' SignatureofApplimntorAgenl- ' .._.-" Dota.. .._._ ...'. ______...."_..." '.__'.' '_".'..__. __._._.___._._._ '...'_.'_ _'__ _._. _ ._.._. .___ .__ � . i. � ___ . .. I / . t_ - . _ . _. . - - - _ - - , � • : . ;_ .. : ., . _. • . , �',"- � . r; TT n= T T N T � N :n�. .� _� "T' _ .-_'� �" _"_� ___ Z �I , � � �p N S ? � � � � Q-O� 7r � � � 7 (a O a 1� � �� � O� G t0 n �„ N o � 2� � � o •c �° o � o D ' o •" o � 1 0 � p s , � � �Z x �,� ' - �� 9 `° �' "_ "'Q �. � � � ,('1 ! �.. T � � ° wl 0 3� n� o o � �m D . ° 0 3 0 0 ° � '�^ � < � a� � v �• o =, y `� � �� � o 0 0 • o ,'°, . o o - � � ;� - � , . . ai o a � o �,� � 3 0 � o . . � � v7.� vn N IDi � C _ � ?' �' _ M IC m . �' ^ d . 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