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0746A 0747A
- � , � / - �-� , . :�� ERS'COMPENSATION DECIARATION ��,. � . . � - . � � ' (/i�Dl� -:L6'�. . . , . ' ' � ...'. f/ Ihof I have u"teiliRcale�of conseni lo seli .''.��s-= ' certiflmteo/Waken'�om��,o,,e���,�,o��e.� , � � APPLICATION` F4�R� �UILDING:'�:PE�MIT'�. . . � ,. �..,�•'� fed capY tFereof(Sec:380p,lab.C.) . ' . . � � ' - . COUNTY OF LOS ANGELES ,,_ ;., BUILOING AND SAFETY - - - � " oMC20 4;9 c,mp,,,Y AR(iONAUT �, . . F - r� Cer. Is hereby fumrshdd. ' ` FOR APPLICANT TO FILL IN a�pREss' �`�'�C'j p ' I~ ( ��%7-�'n;. Certified eopy is flled wtth fhe covnty 6vllding inspeo• BVilOiNG i , � . :lion departmenl. . . n�DRE55 - . . . . ....... .. . . �. . oa�e�-11=86 �,,;�ucu�i dACK LUCLY cm ziv.�_- .. icr..uiir:. 4.: .. , CERTIfIG4TE OF E%EMPTION FROM WORKERS'- � : • � NO.OF BiDGS, rt�rsESi �- � COMPENSATION INSURANCE " 5¢E OF lOT !� � �� NOW ON LOT - CRp55 ST.�: � - � � ��` � �- � �� Y �Thii eectlon need not be tomple�ed if the permit is foi one s.�.' ti�� ' ' ,��d�ad doneR�stoo�o.iss�.� . raaci`42 5�4 � eiocK iar nro: rn�v eoac -� . � ' • v,ec,� o�a� y . .. . . � TEL • � USC ZONE � 6' I terlily Iliot in lhe performonee of t{�e work-for whith fhii �ER • . . . � �. . � . �. .. ' � �'''-'� �J�. .. . .. . . 0 - permit Is Iuued,l shall nor emp�oy ony penon�n any monner � 17 991� MI TCH ELL 5 OUYN - �OAL � . � . . . . .... uui. so as to betOme lvbject lo the Workers'Compenwlion laws. ADDRESS [pNDInONS � �m iaviN�� • CA. Z�P g27i4� . � , Dale� �� � Appllccril�•. .. . . . . ARCHfTER OR . . ...� TEL. ��� � �'.�., � .� .. . . _ � . . � �. NOTICE TO'APPLIGIM: If, aher mokfnq�his Certifitafe o'. - lnSiRiCi GROUv iYPE � � FIRE VROQSSED BY GC E.empUoa,��you shouid be2ome�wb�ecr to the Workers` E�'��R � � -I" �tl . � � ' Ot �-�ompensaflon povi��ons o(thd Labor Code,vo�m�.,ta��ti- „�Eu.30 481.Y ORBA S T• �'1�'1 - �; . :.-r �:- •' = �'�! . : , ; p }ih mmply�wifh�svch prorlslons or this permif shall be_ � � � ; ' ' -' o.' , 3emed revoked,�� T« STAT�STIGL C1ASSiFIG4TION . COIWO. coriraAcroaSAME �lS A80VE rvo. ., -. �:. .'�" ,. . „�y � UCFNSED CONTRACi0R5 DECLARATION � � ii�, . ��O,ASS NO." `�' ~ 'DN'ElL`UWRS � � r { I heroby offiim thof I am Iicensed under provisions of Chapter S ADDRESS ' NO. � - (tommenUrp wNh Sectlon 7000)of Division 3 of the B�sines�ontl . L�C. ��R�P ' Mo(etsiom Code,ond my license is in fulf force ond eHx�. Gry. .. .. ; . .. .-.. . CU,55 � . ' �,'... �._ . �....,:. YAL�DATION ----' ' .: 50.Ff. NO.OF' NO.OF -j.� CHECK � ' � i +: . � LicanleNumber ZBg?16�.... -�UaCIaH Bl �. .. SIZE STORIES � fAMR�ES�-.•, ..� .:� ;. . . .. . . ,, . y,. •ULUATION , - �. - - , Cotiu«+wPRESLRY' oa�e 7�17�l1R_ oexawrioraoFwaeK' 0 N� ❑ 'f ; .;j'; »:J, •. i �-:, �'' . �oo ?`" �:G7bbA ❑I am exempf under Sec.'. � ' - � '- . .. . � . ,� � ! Al1ER e.sr.cr«�ti�:�� .. UNITS 3T7—'�31 �' ` � t t;.�t!!;t:�.1; _ i '• .. . . . . REPAIR �� . . '. .;. , �. � . . : �. G), .. .. .- Dote•. u5e oP .,, . ..:.-•� .� �•:�� .� ' �i N f.�JY��I ,� , .. . . _. E%ISTING BLDG. .... . . .. OEMOL �'�'' ' ��:. . . _ . s:,�s,.: _ . :...... _. ... �`�M�aCK LUC� :.. T�.66o-066o F;r+�� , ` ,•'r'�'Ga�:�r•. ; OWNER•BUILDER OKIARATION �•6ATE � � . � �IherebyaffirriitFwtlameaempthom�haControdor'dtkerise I7JS1 MITG�ELL S�.. iRVINE law fof the following reason(SecRon 7031.5.Businass and. . .. A�u' .F:N L . A.�.�'r�;:la G �.` �� �Professio�n Code): . � Prt .6'f � J . . . . ❑ . . . . . BUaWHG _ . . , . . ,1,m eiwnerbf 1{ia�popeify,or my employees wNF ApDRESS .� wagef oe ihefr foie compensalion,wlll do the work ond � . - . .''., - . . �� the tMucluro Is nof Inlended o'oHered for wle(Sectidn ���.. 70u.B�slness ond Profeesions Code). , MO�nNG - - r¢� • . . .. � - ; - . �G 7 p`�R' � . . u1,os owner ot fhe property,am eaclusively contracring C RAROR� 'NO. �.yl����,�; . . wllh Iicenfed ronhacton to ronslruU the pro(ect�Sea � - AWRE55•...... •:,..: � � tlon 7W1.Biisinees end Profeu�one Code). -.. '..�` .. �''.. - - . '..• � ' ' - . , �'T b�, r' ... REOU�RCO TOTAL SEIBAC � t.,�U �ti Q u ., • ' �CONSTRUCTION LFNDING AGENCY ��gq� rnao Hwr �i�� WioTri � • y .. � • � I hereby oHirm�hnl Ihere Is a conefrutlion�end(ng ogency for .. p�t � . . . , . . !,.S!�1�?��J Q i' the performonee of the work for wMth fhie permit is ksue6 7.L ' ' � �_ , " �� (See.�097.Ctv.C.). Sioe - - O,R.�i��;��1. . . P.L... - . jenderf tJome�..� N�A� - � ' - � . L�MA�ReL�. ' ' � .. . . Lender'f Addieai� ' � . . � -� . .. P.C.F�s S " i� � Parmll Fea � ' ..'./' • . `/ �� I teni Nwl l�iwve�eod this Iitbfion ond stale tha�1he �� !� � � � � � '�` � ' � ►V � � � ly app '. � 7'•� :� � Issvance Fu .i' IDMA�P/C� . . above InhxrtiaNai Is torte[f.1 ogree fo comply wuh aU Cobnfy Inrnrqm�on Fee ,.., . !. � . � . . � � - ordlnonees ond Sble lawa relotlnq eo bvilding eomtrucrlon, " - . Ta81 Fss , I:).�.�~•� �. 'LOM4 Perm.�M,. , ' .� � . � and hefeby ou�horl2e repre�enro�ivee oI�hh Coumy fo enter • - � � � � upon�he obove-mennoned poperry for Inspedion purposes. - ,� . - ' . '• ./ � ' . -. � � � � � fEE REVERSE FOR EX�LANATORY UNGWGE ' � _ . . . - - - � ���� � siq,weu�.o�Appuemr or Apent- � oare . .. . . - . ' . , • . p� � > > o o ° o � T �' o No 0 o n�' „m C) G� = -.S .� • - -- - -- � •"r . : o � « s ? m . 3 . °� � � o ir v �° �am o a o o ° .o o � =m x �v �c o � p S? 9 m o n o V;�. � � o ? :o � =- . T : �? O O E N � P>I 9 O �] ' (p��7 O' � � '�p �O ' . ' � M � O � � O r' { t O � . 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