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1111A 1112A (5)
,:, . ,. . ...:... ... . ... .._..�..-- --- --._ . . ... .... ... _..__..__.._.__ .._.._-----...�._ _._..._.__._..._.. . ....._.. .. .. ._... __.._..____.._..:. .� .YJORKERS'COMPENSATION DECLARATION �"' ,. • , . ... . ; .., _ . . ��� .�. , P . ,,. •'-_......---.._._ :� .. . . •,� .�,,. , ,� . orharcertifed,co 1hahereof Sec:C3800cLob.o�.cansen�to,self ' ...'.� . �:.. • insu�e,orateilifimleoFWorker5'�omensa�ion��=�.o��a, APPLICATION��F�R�,'BUILDING� PERMIT��� �- � � , —-----�---- - — -- -- ' � � ' 73N1C005-2�9-0004 Natioraaide 10�8 COUNTY OF LOS ANGELES BUILDING AND SAFETY :; , ..; : Polity No. � � ompany �- _-- - ' - - - � Certified co is hereb furnished.� " DING 6 0 , PY Y ,' FOR APPLICANT TO FIIL IN eun ❑ _ AD�RE55 85 N. Feathe.ti��od Drive Certified copy is filed with tfie tounty building�irispec- BUitDiNG 685 N. FeathezG�od Drive �tion departmenl. • ADDRE55 - . oo�e�,: . 6-].9-$y�Pl��a,;r.. THE.P.NDEN�GRJJLTP� aTr Diamond Bar Z1P 91765 Diamond Baz' � LOCHLITY . ; 1 "'� � � CERTIFICATE OF EXEMPTION FROM WORKERS' ' �-"���- '" '-�'-- ' - --- �� -`-�NO:OF BLDGS.- - � � �- . NEAREST _ ._, _ _._._ . ._� � � � � COMPENSATION INSURANCE " '� `� ' SIZE OF LOT NOW ON LOT CRO55 5T.H1CJt1 KTKJT� S.GOZCIPII SpY'1T1C3S (This setlion��need nol be compleled if Ihe permil is fo(one -- -- - -----3rj�](]r-- �-� �-�-�- -- � -�-----�jj----� ASSESSOR,,,,.,, --- � -- - - � % � �- hUndred dollors(5100)or 1e55.) . ,. . ,, TRA BIOCK LO& hL47 BOOK' ' � GAGE' PARCEL :.: .. TEL. U ZONE M1MP J� , . � , .. ,� . . owrhe- THE ADIDE[J C�20UP - —No. 967-9541� Lcerfify ihot in ihe performonce of,the work(or which ihis �� NO. ! �z3"'�y" ' " - pe�mit is issaed,1 shall not em lo on '' y ' . -.. ..... ...._ .. ..___.__ .._. } P Y Y Person m on manner _-_-- P.O.Box.3329...- ---..... -. -- _ - -� - sPec�n� -- � ., . a so es to become subject to tha Workers;Compenwtion laws. ADDRE55-� - - - QY?� CONDITIONS Q . . . .. , , ,: Covir�a 9ll22 -- - -- , � _.. - ' — - - .. .. . . . .,�. _ __ -._'_ '_.__.._21P _._ __.' � . Cltt,._. � �TICE TO APPLICANT:PfP,l�ofter moking this Certifimte of ARCNITECT OR TEL 44 ' _D157RICT_ GROUP TYPE. ___ _FIRE_. .PROCESSED BY.. _ � ._ ENGINEER �VG .S No, 5-4073 : ..em tion, ou should becoma subjett to tha Worke�s' �-' CON�y. �yE witb�mm I with such ro1he Labar Code,you musf forth- • � �/ q�/ I� '�' i� Com ensotion ro�isions af�isions or lhis permit sholl be A�DRESS Q t Arcadia 91006 � � jb --- �{,'3 j'� .J"' --_ _-'J� � .-... P Y P P PY P I here6y aff�mEN�S�ED C�ON Cen � � � CONTRAnOR�� �� � Hp, C4TION I APT. CONDO. �z � deemed revoked.•�: _ • STAi1STICAL CU1551FI � � '- .... ..1.... .._, . _ ..__ / ..._"__'_' . � CTORS DECIARATION,..., ... ._.... - - . ...__._.. _ -- . - '- -...t�C. - - - ---�� an55 NO.'..�� DwFu.uNrtS� sed under provisions of Chapter 9 ADDRE55 A$ cI�JOVE r,o.371580 (commencing wiih Section 7000)of Division 3 of the Business and .'--.. __..__. .... ...-'-. ----L�C. ---.B. - �R�P � � . „ . , . _ _ Professions Code,and my license is In full force and eifect. CITY CWSS � '-' '�"'-- - �-- - - �- ----- . . .�. . . ... .. .. .. ...... BK. PG.� , . ; . 'VALIDATION ., ..., .,,., SC].fT.:1Q46-- NO.OF . .. NO.OF_.'_�. _..--CHECK, � ' ., f Ucense Nomber 37�'S80 Lic Ciesg�B' ---_� SIZE STORiES FAMIUES ONE - � - ���. , - � vawnrioN - - -: _ .__ .._._..........- ---�= . ., .,�THF�ANDEDT C�ROUP �� �. �:•'F)I��HF) '....._ DESCRIPTIONOFWORK"S' 1.2'.f�j� ...-_._. NEyy_-� s . 54,000 . . � COnlraCtor Date ���, + � ❑I am exempt under Sec. . -----,-Gc�dJ2_4�IO-SF---.. ------ noo ❑❑ ,. - - _ `-� � �.-� A_!; � � � . . AITER . � _... _._ • . . 8.8P.C.for Ihis reason ... REGAIR'-� f�-�' ' " -- -� - - . ..- - --..ir'• s e.e-2�_"_! .'.. ..__._ _ ._" ' '_'" ' ' USE OF � � ' -� Dafe:- - � EXISTING BLDG. DEMpL ❑ � _ _ -- 1.�.231.1 6- _ -"-Signature .... .- . .. .�-----`... ..•:� .. . - APPIICANTri� � G�� TEI. FINAL ' OWNER-BWLDER DECIARATION _.._ ..��Ni e NO. ..�ATE-Z-2�-'�''.. . �--'.'-'• .`.°.2�.1,,]O,u-- -�1 hereby affirm Ihat I am eKempt from the Contracfor i litensa . �aw for the following reason(Section 7031.5, Business and ADDaE55 FINAL''/ �� - . U Q 2 L-�'C) � � ' liesii"ons Cbde):. .. . .... .......-'__-""'. . ' --- Pe ENT . � ..6r.. _ _ _ � . .. ._. � ��� 'i Ej I, as owner of the property, or_my employees with ADDRE55- � ' ���`•��-�` '��'�'-' �'``� �' wages as their sole mmpensation,wil�do ihe work and '. ' " ----.. . . . "� --� ' . - ..... ._ . � . � the shuctvre is not intended or offered for sale(Seclion ��"��TY�����" •�� t� • .����-� -. -�� ' ' � � . . . �`� '��-' -�7044,8ustness and Professions Code). -- -----'-- -'-'- MOVING� ..'.t-'...._.._. . _.._ .,: 7Et. - .. _... . ..- --- ��. _ ._. :.. ....... ....___. _ � I,as owner of Iha properfy,am exclvsively contracting CONTRAC70R NO. � , . � , . � with licensed conlroUors ro construct the project(Sec-"--- . ._..-----�' -�--' ' "-... ...-'-"�-' -� ---- - �' -- ._. ...... ........ ... .._ .. __j_'.' __ .-•'_-'E;�._�..�.2 A... tion 7044,Business and Professions Code. nooRE55 � � ' • ) _,7 j�-' �•`� � �'�`.''� . � 'CONSTRUCTION LENDINGAGENCY � �""" '--'--� REOuiRED YAR�' HWY -TOIALSETBACKFROM . %I , _. .__ _.._.. � '1:_ . .CI„ .�.�_• �. _ !�� _ , $ET BACK PROP.LINE WiOTH ..=..., I �� . I hereby affirm thot thera is o tonstruttion lending agency for FRONT � � f:: .,.. � 1 (•�• .`:.i-' � �J�.6.�� -�'i � the performance of tha workforwhich this permit is issoed - -- �v.L �---' �--'� ---- .._... ._...._._...-.'_- - .-. -- .- _. . . -.�-..j ----_ - _'-''._. _.. . . (Sec.3097,Civ.C.)• SiDE _ ' ���_ - . _ . .. ,.. . .----- - -- � '� �� .. ne�j � _.__ '_-__ ' _ P.L _.. ___'_ .._.__�._.. � . v Q U�� I Lender'sName �'1Lt�{'A1 Tl1iYY1iR ---.. � - --- -' .- '-'_ . . .__.__ _- - .. -'-...__. ._ . -231 S. IaSa1le,Chieago-II, P.e Fea a 231.16 --- P�•m��ree--325.SO _.' LDMA Ref.M ' O H,2 C��6+:� : . '--. --- en er s A ress � - ' ,.._,..•,�.� ..`� I.tertify thol.l have read ihis applicafion.and slale that t e 693 . --........_.. �_ __--._ �ssuance F�e-10.5� -.. . ` IDMA P/C M .. -. -. '' - - I--- ' _�_�__i.._�-.__; above fnformotio conect.I agree lo tomply with all County Invesr�gaiion Fea ' � � ordinances a te lows relotin to b�ildin constroction, � ��� � - � � 9 9 .._. ._ ... ._'_._'_'__._____ __- 7orolfee_-336.00 " . .IDMA�Perm.N . ... ._ -. ._ _ _.�'_'.'__ ..=-�-_�..� and hereb u rize represenratives of this Counly to enler �pon h oned property for inspectio urposes. . � _ _ - - �'r� �� --- --- ._ --------- - -- - ------ ----- . --- - -- -- . -__ -- : � . SEEREVERSEFOREXPLAHATORYLANGUAGE ' ".' Signa�ura of Applicon�or Agent_'.---.._ . Da�e._. __.._'_"._'._'.'.._ _..__"__.. _"'___"..... ._.._._. .._.... . ... _,. __ _ ....._ ..� ."_'. _- _. __.-. _.. OO� " Z �o -� o � . .. , . � ' ' -�� • - � -�- -� o '`, -G1 ..� o o � �- �` o :? �-v+ �a, o, 4 � ,m 9� � .! v � �p p _ s' � 'O O O � f+N �• lO p � � O� � ,y O � ~ F Q n p �O ', 3 O �.Q << . � , o �'= n� � A :3 `,�o °' .�O- .n u+o ,p � 5. o v _ � m �•. . y �+• o m o o a�.: o'o.. �' •� 1� � Z . 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