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1085A 1086A
. :... . ... .:........ . _. ----- - � • .WORKERS'COMPENSATION DECLARATION . . .-_ ; .-."..... `.;� .'-.'.... .., .._. ..--- -..._... ... . _._.... _ . _ _ ,...._._.�...--._-"-" ; .�....... ., , . ...: � __._ . ......'-- - � " .. , . ' . . I . I hereby aFfirrq�hat�hove a te.fificate of•�o�,e�,�o,e�f qpp��CAT10N FO.R-;BUILDING. PERMIT��-����� � I Insure,or a cerfificate of Workers'Compensation Insurance, ' or n certified copy thereof Sec.3800;Lob�.C.�'t"' ' '- - -' "�"�-- �"-� -- - - � ' '�-�� � � � '>• " • • � COUNTY OF LdS ANGELES BUILDING AND SAFETY � � ;.�.; , Po�tcyqawrnn4=�79cc004YNai-;ni�xuir3c� - 30 C .. �Cenified co is hereb fum�shed:��:�:��. ' nDDRE55 72� IQ. Feather*aood Drive � � O',' PY� Y ' ' FOR APPLICANT TO FILL IN , � Certified�copy�ii filed�wirh the�caunry building'inspec- ' - BUnDwG']ZO N. Feathertaoocl Drive �tlondeparfinent. , ... .. .� �.. . AD�RE55 � � ! X�1e,6-19-86.,:�•qppl�cam.Tf� ANDEN.GI�JP _. am Dia[oOTId.Bar Z1P 91765 tocnt�Tv Diamo�i Bar �` '��CERTIFICATE OF EXEMPTION FROM WORKERS' �� - - � ----� --'-� - ��-NO.OF BLDGS-- --- � NEARESi � � ' �� � � ���•���'COMPENSATIONINSURANCE'����-�•� �• . SI2EOFL0T NOWON�Oi GROSSST.Hl H Kmb�& Goldeii Spririgs - � � - , •, . . " (This'settion-need na�be'completed if�the`permil fi�for one -- q�'7�� -- Zrj -� -----� � -- �� �.•:;-�. TRACf�!�'F� BLOCK lOT � ASSESSOR. . , ; ; hundred dollar5(5100)or lees.� . .,� , � MP.P BOOK � �� PAGE' PARCEL ..... .. ........i . ,,_,.. . . .. 5�,�Z MAP ' � _ ovm�ea � ADIDEN GId�7P - - No 967-9541 �/ � I certify�ihat.iq the perFormance of the work for which�ihis ' Uf�,� NO. ' ���3y � ' permit is issued,I shall not employ any person in ony mariner C�� � �- 57eCini -- / ��-� - � -� -- 'O}. � . . ,. '_ ADDRE55 P.O:BUX 33Z9 '. . _... ._ _- ..- ... _ - /UV7� GON�ITIONS � ' so as l0 6ecome svbject to'the Woikers'Comp'ensolion Ldws. 'v , rTICE.TO APPLICANT: Ifllofler�makm this Cerfificate of ENGHNEERTORDave 5 AIA No`'.1445-4073� o�sTR�cr_ cRouP TYPE ,FIRE PROCESSED�BY� ,� I , . .. cin zie PP O emption,��yoU`should betoma subje9l to�Ihe�Workers' CONSi. I ' ZONE . �j ampensa�iomprovisions of tha Lobor Code,�yw mvs�forth- ?S �j J�/ �/ �W with mmply with such provisfons oa�his permif shall be __ _ A�DRE55 � . ld 9�.00F) �- I���- �r- --�G-1" �Jb � -� - ,N deemed revoked.� .. � �� � �� pi�IN G�jJP TE�� STATISTI�AL CLA$SIFICATION ' APT. CONDp.- '� Z •. ..� . "� ....,. . '... CONTRACTOR NO. . . ,.•.��, � __ . ... . .' ._ __. _.... ..._ . • IICENSED CONTRACTORS DECLARATION�..�• ,`• - -- .���. - - . CIASS NO. ��� DWELL UNITS ' ` I hereby offirm thaf I om licensed under provisions of Chapter 9 ADDRE55 AS d�70V2 NO. 371-58� ..- UC.��B- . SEWER MAP (tommencing wi�h Section 7000)of Division 3 of the Business and . . _ , . __ . � � ' -- Rofessions Code,ond my license is in full forte ond efiect. CI7Y CLASS -- - - - - � � - - - -- ,.. , . , . . ,..._ . , .. . . . . ._ SQ.FT.17H6� - NO.OF __ __ NO.OF „1____ CHECK 8K. �. ' ; � VALID�k License Number�� � 3�]1,�jSO LiC.C�ass_'��'� SIZE $TORIE$ FAMItIES ONE �� ��� ' , , , , , � . ` .. . . . �. . ... VALUATION__ � ' .:, ; „�.ZFIF ANDEN GROUP � . '�F)�19-HF1 ._ .. DFSCRIPTION OF WORK �S� �.2 fBIfLl.1 . -_ NEW- � 65 320--;- --- -- . .-.. .�'�� • •2 1 -: ' Contmctor Date s � . , �� � . . . _.__.. Garage 445 SF- -.... -- __ noo. ❑❑ - I •2 G&6 5-. ' ❑I am exempt under Sec. � -����-� � , � . AITER .. ' _..'_' '_' �. .�.. :. ; ^ .., B.BP.C.for this reason . RfPAiR .❑ ..S .-"-- -..- . .-'- - - : - . ..e..o�_(;F(��u. ' .._ _._ '_. .- _. . __. ___ Dote: . ..... . .. __. E IST�ING BLDG. DEMOL ❑ � _.. 0�.2 2-8 6 _ . ` .. _._ __._ . .._-Si nGlure - APP�IG4Ni TEI. . ' 9 __._. . ----_-- PRINT TIiF ANDEN GId�iJP NO FINAL ' ! I. OWNER-BUIL�ER DECLARATION .-DATE � .(��F��.._ .__ ..__... _._. � '- - � - - - - -� --- .. . . .. .. - . .__...._. � -I hereby affirm that i am exempt from the Contracror's ltcense � � � ' , _law for�he following'reason(Set�ian 7031.5,Business and AODRE55 � �Ve � FINAL '' '-" � • ' �ofessNl,o�ns�Co�deh=ir•oi_com P n•Yhen,will do the work cnd - .._ ewmiN� . - - . .. . . . -... ._ ..-,. ,^.i ._-" - . ., I . ) . .... ...... __. PRESENT 'By ��_ �� I, as owner of the ro ert, or my employees wifh ADDRE55 � � - e A .._ __. R�n, � the strvctvre is not intended or offered for wle(Section ����T� , � ; � � �V � . � . .-�- 7044,Business and Professions Code)......- '-� ' �'� MOVING. . ._. . ... ... - �- - TEL. '.. - - . . .. -- --� ° � � -- � '�-� • e • e •��.'.. � ❑ I,os owner of the properry,am exdusively tontracting CONTRACTOR NO. ' -• . - � with licensed contractors-ro construct the pro�ect(Sea '---'- qooRE55 .. . _....- --. _ . ..- - � - . . .. .- _. . .�... _.�.. . -� -'- ` - '---� ..r �3�Q��--�-'�.� tlon 7044,Business ond Professions Code). � A v�Q 0 O�_,- � ---"_""-'.' REQl11RED. iOTALSEBACKFR M_ I _ ' __ "'_"'""... e . -CONSTRUCTION LENDING AGENCY " -"�- `�-' sEi eaCK YARD HWY- PROP.UNE WiDTH ��� • ! I hereby affirm thol Ihere is a consfruction lending agency for FRONi "�� '��"�'+.;1� � �� .- .,;.: 'y,. . Ihe-performance of the work for whith lhis permi�is issued --�- - -p.l. ' •"' 0�2 2�8.b _. , .. . .. ._ .. .. - - - ------- -- -- . _. . ., . _.... _ _._.._ .. - �- - - (Sea 3097,Civ.C.). SiDE � � ��� � ' I ��_ CO11�.1.TlE?ri� I�.I.1T1D1S' __ _ _. P.L � lender'S Nama - .-..-�-� - � ---- � - � --... . .� r. �-� . .. � , .� � ' LDMA Ref.M �-. ..r.,� ,�'_. �"�' ,. ._ ' ` 268.65. ' _ .. _ .... ...10.50'- i�n,w vic x - � � ��� 9 P Y'^�� �Y Inves�i ation Fee ` '--' �. . _ .., . �.Ci.��.S eC Ca � P.QFeeE�- __ _ PermitFee 379.50 Lender's Address � � � � . .I certify ihal I have.read Ihis appiicalion and slate.tha e 3 _ - IssuanceFce-- '- - ' , _ . above in(ormali is torrec�.I a ree�o com I ih oll Coun 9 _, � � ��- � _ordinances a iare laws relating to building tonsfrocfion, , .__.__ _ To�al Fee ---3 O.00�� IDMA Perm.M ��--�� � " � ' __ ._. .. . .'. . _ '... . � and hereb orize represemoiives of this County to eMer � �� '- - �" - - upon th -m ioned property for I�spectio urpo es. � . ... .,� _ - - LDMA _ :.$75 - - $35 - - _ -- - - -.. . .-- - -- - SEE REVERSE FOR EXPIANATORY LANGUAGE � ..._.-Signorure of Applican�orAgent __. .'___.- _ ore.' '. ... .. '..' . ... . .. 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