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1087A 1088A (5)
� Y � �� . . �,�.,� -`- "-...._._�_....__..__..._,...1._,.......-: ._'--.._ _L._......-..__�.'...-.. ,..___._...._.__ .... ."� -..'-- -_.. _. ..... _.___ .... WORKERS'COMPENSATION DECLARATION - . ; '�.. "" � :'� �•': � I here6�aifirm that I have.a cerlifiwP oF��a�Se�,�o —���� -----��APPLI�CATI�ON�__FOR _B:UILDING PERMIT��_ -����� �:•• . � �5e�r �nsure or a certificale of Workeri Com ensation Insurante, . or a tertified topy ihereof(Set:3800,La6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFEYY VolicyN��005-279�a(�,�Q� _Nattonwide� �� _ 30/C _ � O Certified copy is hereby fvrnished. � FOR APPLICANT TO FILL IN euuo�NG ADDRESS �'�CertiFied copy is filed with the counry building Snspec- � BUILDiNG'748 N. Feathexwood Drive � ' � � Iion departmenl.'�'�� ' ADDRES$ , � Da1e •G-�.9-H6�^�APplifoN����IE ANDIN GROUP CITY DlaifIJTY� Bcl.r 21P 9].�](rj lOC4lITY Dl�[Y]IX� $c3T . � � �� CER7IFICATE OF EXEMPTION FROM WORKERS'"� '�-- " ��� --' ----- �-- �� �NO.OF BLDGS. -- � -- NEAREST_.___._..._._. ._ .__._ ...... .. �� � � ' �COMPENSATION INSURANCE � � . S2E OF lOi NOW ON LOT CROSS SL � (Thii settion need not be compleled if the'permil�is for ona � � - - - ASSESSOR- • -� ' hund�ed dollors(5100)or less.) . ,� � TRACT 3576L BIOCK LOT 22 � Mp,p gOpK"�� ' PAGE' PARGEL � Y.. .. , .�.• .�. TEL USE�ONE �P �3_� , ;a � . ... � . ., .. . .. -� pWNER' _ ' .NO. / permit is issued,Ihs performance of the work for which this , � �/ � �' '� ,.. . hail not emplay ony person in ony manner ..__ ._P Q. BQX.332g_.__ ' ��r..._ SPECIAL-�- -'--- '- ---'-----"-' ' '--. ... so as to become sobjecf 10 Ihe Wo.kers'Compensation Laws. /+�RESS -- - - --- � ------- COND�TIONS �V , �..',. ,� . . „�. -.:. . • . . " ' . � 'r�iF`'A�EN GEa�LTP arr . COVina... _..._ ... . nr .91722.. . ` - .- - - - - _ m F-19-S . .. _� te ' ".. �PPliCant -= - ARCHITECTOR TEL. .•. .. :0 TICE TO`APPLICAM:'If;�after making'�this'�Certificale of ENG�NEER N0.4Q -4 �]3 � DISiRICT.. _GROUP NPE � _ �� FIRE__ __�ROCESSEDBY .F. mptfon,''you should become sLb�ect�to tha�Workers' - � ��T' Z ;W Compensation provisions of the Labor,Code,yoo must forfh- ADDRE55 314 N. F].rSt� Arcadia 91006 .� j o.__. �3__ �(../[�, . _ �"� ;N with comply wilh such provisions or �his permif shall ba ... . � deemed revoked. � •,�,�„ TEL. � STATISTICAL CL459FICATION APt. CON00. �:2 +,. . �.,�;.�,.. ..•., •. .; ��•. CONTRACTOR ��IEi ANDIN GI�UP No..91006 -cuss r,o. owEu. 1 ' _ [A -: - -F/ _.. . ' IICENSED CONTRACTORS DECIARATION-, � �' -� -� �-�� �- � �--- -- -�-------�--ii�;---�-� � � uNiiS � I hereby offirm thaf�am licensed under provisions of Chopter 9 ADDRE55 NO. ��R�P (commencing wi�h Sec�ion 7000)of Division 3 of the 8usiness ond ,, . ._ _._. _ , ._ _.__ _ __. ..- .UC. - � � � � Professions Code,and my license is in foll forte and�effetl. Ciiv Cu55 B - --- - - --- - - VALIDATION ' , .,. . , .., . . � � ' � �� '� ' Sq.FT NO OF NO.OF CHECK ; BK� �'� � � �'. •SBl�umbe��.. 371580 .'� 1ia[I6si �B � - size.1786 STORIES.. ....- FAMILIE� ONE � V , ' � _ O�'7 a� . � . . �. ,. � . . . . S� 12 fdID1�. [� .- AWATION- � ' -- - .���. .... Licen , I�' �T�I�.'.ANDIN CF�JP�' � (-].4-$6. - - OESCRIPTION OF WORK.. � - • y '-�- N�'-�FJ 65 320 � -� -�- - . CoMrdctor i�• Date ADD � s � . � #.e• •��2��. - ' Gara e -445 SF. .__. : am exempr under Sec. g � � � o , , - - - - - A�TER-❑ ► `_ � •26865� �� ,.. . , ., . B.SP.C.for this reason '. _ _ REPAIR.� -:_-��'----'"-"'"--.`-"--. ..�-"-'-"-----�- - - -r .. . . .. USE OF a { . , ��P G�V.rJ�+ . ._.__ . .___ ____. . .,. •. � . ' '_'"0o1e•' . EXISTING BLDG. �EMOL _._.� ...._.... . .. . ...- ., ... _ 9 ��.i.`. __..."' ' '_...... . . " AFPLIUNT TEL. ._ . 0..�?2`a b � Si-nolure . _ . .._.... • � FlNAL OWNER-BUILDER DECLARATIDN _ PRMT�� �� G�� NO. ._.DATE��L'IG- �� � _ _. -- . _... �I here6y oiFirm�ha�I am exempt from the CoMrocfor's License qD�RESS AS 3}7OVB � � � � .��aw for the following reasort'(SeUion 7031.5,Business and FINAL� G� �' � � � �fessions Codej•'-'-" _.._... .. .-- '-....�....-' . . ---- aRESENi eY__ _ _ .. ..._.. .�. .,. . .. . ._ _.'. BWLDING , . ,, � I, as owner of the property, or my employees with ADDftESS ' ` : -�-wo9e3as iheir sole compensarion;wilfdo the workbnd ' - � �--� '�, iha strucfu�e is nol inlended or offered for sala(Sectton ��'��TY ' � ' ��" ' � ��-wHh licensed conimctors fv mnstrud Iheproject(Sec- .. _ GONTRAROR " -- � ., _�-_'"..' NO. ; ���� ���� �W' -��'��-'- �� � "� _. . . • s . � I,oas o�4er osf th pP�perly,fam e�tlusfdvely contracting ADDRI u . --iEL.- ' . ..--- --. .. _. .' '- -i i r �'.�� Q��A i ° -- Yon 70 ,Busness a d Pro es o s Co ). ., , ^-� _ .. . RE�UIRED'_ 'YARD HWY. .....iOTALSEiBACKFROM XIT. . __.._.___.__ ' __` �.:-" :.-,.I..'.J_C/QQO '. -CONSTRUCTION LENDING AGENCY-- " " SEi BnCK PROa.urvE WiDiH I hereby ai(irm tha�there is a constrvdian�ending agency for FRONi �� ��S'-`� - � • • ' the performance of rhe work for whith this pe�mit Is�ssued - -�v.t.-- - -_.•''�"! �':-•''.�... _-. .3����C O" - —-__ _�. --- - -�- � �-- � -- -.. ... .. __ ..... . .. . (Sea 30g/,C�v.C.). sioe 0 8 2 2�8 6 _... - Continental 2llinois-- - - - .`. _. _ ---� -_...'.. _.. ' a _..... _. � Lender's Name _ _ .268.65 LDMA Ref.N � � �: •; ; -- P.GFeeS--^ PermitFee 379.J�� - - � - - - -- • - — 231�5� LaSa1le,Chica IL - . __ - lender's Address � � �- ��• � - � ! I terfify that I have read this opplimtion and stote tha�4A�93._ ...... .___ ._..._._. .__ . ,,,�a�<,F�e. 10.5�. _. �pMq P/C• ,_ ---. � _�`' �' � � _ --.._- -. -- ---� - � obove information i tonect.I agree b tomply with all Counry invesrigaiion Fee '� ' � � ordinances and laws relating to building Conslm[tion, � Total Fec-- �390.00 - � "��� � - _ _ _. _..... .. .__. .' __.._. ___. .L�MA Perm.N __' . .,, . i and hereby z represenfa�ives of Ihis Counly to enrer . . ; opon Ihe o v enr d properry for tnspection p rposes. LDML�-._ � $7Jr .. _�_ : $35 _. _ _ __ _�_ _ . _ - . ._. _ _ I 3 ' ---- - . .... 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