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1157A 1158A
, . . . . ..._ __.____.____._. __._.._. . ___.__._...�_,_ _. .. _. ._ . -- - WORKERS'COMPENSAiION�DECIARATION _. .-'-- ' � ''. � :r �.,��.. . .. ." .. .... -.- _. . :_ _ `_ .. :_-'.,.__ —" -_� �' ,��e�;�°''��m ,h°" �°°a°�e�°`��°'e°'.�°°se°'',°°°" �-APPLICi4TION-FOR��BUILDING� PERMIT - . insure,o�o terri(imta of Workers'Compensotion Insuronce, � . '-".- _ --_._ _._... . __ .. . ... - _ -. - - . or'acerlifiedtopyi ereo (Sec.3800.Lab.C.)..,:'.•.� . . .__. __._ , � Pouc No��005-27�o,�Q� ':Nati.onwide' _ _ 60/B (2 Car) �OUNTY OF LOS ANGELES � BUIL0ING�AND SAFETY •,; ,. ! a " . . . � : Cer�iRed copy i:hereby fumished.• • FOR APPLICANT TO FILL IN BUiIDING � nooeess 743 N. Feathett�od Drive � Cerlified copy is filed with the co�niy huilding'Inzpec- �-� BUiIDiNG �43 N. Feathexsa��od i.7xive , � lion deportment: - - � ADDRESS ' 1 , , , _:.:_. -- -- �ocAun , ' D'ate 'Fa$�f.6�14^a�pVm � ..',. ,:I , �•.,�- .,.;, ---- --_._...._.. -- ---- - i ,,, �TEIE PSIDIN�GRfJUP arv Diantoirl Bar z�v 91765 Di�tiorxl Sar CERTIFICATE OF EXEMPTION PROM WORKERS'" ' """-� """""� �--� �--- -'�� �"N��OF BLOGS. - ---- -- -: NEAREST.. . .__,_.._.__.___.._.._ .� � �� � � '�COMPENSATION INSURANCE'� � .. SRE OF LOi NOW ON lOT GROSS ST. Hl Il KIY)b-&.C�ZCZP.l1 S Tl S . . .. ,� ;.. � (Thie seclion need not be camplefed if the permit 6s ro.�o�a ---- 5761-- AssessoR... �—--�-- �----� �•-�� - _ . ._... __' ._'_.��_ . .._ - ._.... ; ._._..._. . hundred dollars(5100)or less.� , .. � TRAC7 - - BLOCK LO MAP BOOK' " � " � PAGE; PARfFI � , owrrze -7i-IE AI�IN GF�UP nio 967-9541 ��/�"Ej r oP � - �' �---- --- �-3 I�certity�that in the�performance of the�work for wh ch�hie � I permtt is�ssued,1 shall nol¢mploy ony per5on in any monner ��.�� -- SPECIAL �-- � �- ��-- -� � �'LL so'as to became subjett to fhe Waikers'Compensa�ion'Laws. - -� AD�RESS-- � � -- --�-- - -- ! � CONDITIONS f V � � ARCHITECT aR i(E}L1722 GROUP � ' ' fIRE_ ,PROCESSED BY. , ' - . ,�. ,.� ., ._.... CITY . CO�lI]a. __.�.'.'__-..ZIP _.__ ._. : '_'.'__. '__ . .00 �e . . , .. .qPPlicant��� -- . ' ,� _. . . In TICf 70�APPLICANT: If, af�er mok�ng tfiis Certifimte of D�STeKf t�ST. E ��j I mptio�;'yeJ"should become svbjeU��o�ihe�Workers' ENGWEER lldVO S23 AIA No.445-4073 �- �ampensation provisions of the La6or Code,'you must farth- ADDRFSS 314 N, F]YS't� AY'G3C�7-3 9�-�06 _ l l7__ � � � � 'W with compiy.wilh�such provisions or this permit shall be --�-- � TEI. � STATISTICAL CLA59FICATION � APL CONDO. deemed revoked. , ... . : . � ' ,. , THE ANDEN CiE�UP : — CONTRAC70R NO. . ' _'_..' s2..f.. . LICENSED CONTRACTORS DECIARATION '�-� -- �-� -� �� ---—- -- ---�-- ��-- M55 NO. � �� �DWELL UNITSJ__ � Z } ----AS' Ve-- uc. I hereby affirm Ihot I em licensed under provisions of Chapter9 ADDRESS No.371580 (commencing�wifh SeUion 7000)of Division 3 0(ihe Bosiness and ,_..._ ���_. SEWER hUta , � -_ _.-' '._.. __. . ..__ . -"- - B--'. _.. Professions Code,and my license is in full fo'rca ond effect CITY CLnSS r �'- '" - "-' ' '" "- ""`�VAUDATION"- ----. - '� �� � � '� � ' , NO.OF_ CHECK I BK. PG , l�ense Number'3�15H0 '". Lic CIOS! B '• . . �EFT.2375 STORIDES � FAMILIE$—'1''" ONE . , � .' ... .. -.. . � . VAIUATtON ; � I am exempt under Sea -� ----�----GdTdCJ@.,Sl� SF-'-----...__.. .. A�R _O -�- - � '— i --. �. . .. - -:��'1��7 A '-: co�o-o�ro:T�'�IN G�P Dale 6 �'9�86�, - - DESCRIMIONOfWORK S' le f�vn17. � s $6�080 _ - - 7.e e •.�21 .. O 8.8P.C.fo.Ihis reason� . . . .,. . .. --.'.-' ❑ -._;...._... _.. _.._ ' '.,. _.._._...��•�J�-I,���-- . REPAIR- .. ...__._. '.__ _'__".. _.__. �- ' USEOF : �a�ec --� DEMOI ❑ � � EXISTINGBI�G. -'--.- ..-. .. •J.)�.'� �V �. --Signafure" " . � ._.- _. _. _____- . " APRPP.IMI��' �`IDIN �i� NO. I FINAI /!�i "__L.._., _�.�.22'�6... �. OWNER-BUILDER�ECLARATION ____ . _._ _____ ._ ... ..... .... . _ --DATE-Z"/ ---- � 1 hereby affirm that I am exempl from the Contmctor's licanse ��u Ve� ' „ . ' Law for fhe following reason:(Section 7031.5.Business ond /+ODkEsS ' flNAI'- '- '� � �" � _ � ....... _"-'-.--" .. -.' . � - -_ �jfesstons Code): . . _. . ... _. ... Pae eNi y� . -. .. � - . -..�, -- h BUILDING I _, J, 1, os owaer of tha prapeNy,or my empioyees with nDDeESS ____. ___.__ ___ � woges os their sole compensalion,will do the wo.k nnd �_�8 the strucfure is no�in�ended or offered for sole(Section ��`��TM � ' i . _ _._.-7044.BusinessandProfessionsCode�. ' _... . ' '__ MOVING__..____" _ '.___.'_ ._. .. TEL:."'- __..._... .__ , ._. "_ _. __.... _.. . ,_.TM ,_e.. ❑ I,as owner af the propr.rfy,am e.clusively controcling CONTRACTOR NO. � . �- , �A with licensed contractars to consrruct ihe profect(Seo- - _ ----. -`--- - -- .-'- --- -- - -- - --- - - . - .._. -I �4 8�1.5�}_' ' ADORE55 �'_y...%�: " .:f�- I�'..�i tion 7044,Business ond Prafesslons Code). , (,p�i . '� � ', . RE�UIRED._ . _ ..i07A�SETBACK iR M . k� ._. _ ' Y 9 9 Y fROtdl YARD HWY _ _- .'_.. ."_'_ '...__'.! . __'_';+''`-`'.�� _�..!' �• . . e A.. ~ -'.-.. �- '�"-CONSTRUCiION LEN�ING AGENCY " SE7 enCK � FROa.twE W�DTH '� °U���.J O� I hereb offirm tha�thera is a mnstruc�ion lendin a enc (or �,!?� ���1� '�- � i �Ihb performonce oi the work for which�his permit is issued �-�- � �P.L---- � --��- � � , � � ,� ti • �C 2'2��II 6.-�; (Sec.3097,Civ.C.�. SIDE , � " , � -- -- --Confiinen�31. Illiu»is- a.i. - - -- _ .. _-'-� < < •_s •' _ ; � Lender's Name '' ' ...� � . � LOMA Ref.p \�. � ' - ' �t - 231 S. LaSa1le;Chicago IL �� 331.12 474.00 - -� • , - P.C.-Fee S� . Pamit Fee ' -� tender's Address 0693 � ' � _I.cerlify thnlJ.have reod Ihi:applicetion and state thot th ._ _ _ ._.. ._..._._'___..... Issuance Fee.-IQ.SQ ��--� -�� IDMA P/C 11.. ..... . ........ I._.. ` ..'_ - '.� abpve informoli0n ie correct.I agree to comply wifh oll County Invevigatian Fee Q84.5� � � - �� I o�dinances and fe lows relating ro building constroction, . _.__._._._.... . __._._ � Torol Pee- - --�-�- � tDMA Perm.N -- � � � .--•-'. --'. ..- _-`- -. . ..._. ..._. . ond heraby h ize represenlotives of this County to enter ! � upon the ov me ' ed property for inspeUio purposes. -$ _ .;-.. __ _ _ _ . . .._..... _ .-.-..-- - �_^--- - ----- -.. '. -, , ILY�'1A - 75 $35 _ _ - --- � g��p SEE REYERSE FOR FXPLANATORY IANGUAGE ..._..._Signorure oi Appliconr o.A9em . ... ..- - �Dore__ __ . .__ .__ _._ .. - . ..". _- . �Or� - Z ;o . � � -� o • ,G�'-�� o, � _ -`1" ',�i ,G�' � � �'°- �t $, <O ? :t'� y \ o � �-N t0 O.. 4 1� '� i O ; � � , ,0 � np (D f��N IP, � ��p �^. b��� .. O ) O Q n p .�i:p O � p �O . Q..,: , ' r '�` o � �'�� � � 3 m . � . y -t� iP O t�0 7 �7�.o�: ��"� � ' ..�. 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